How do I explain a Do Not Resuscitate (DNR) order to a patient's family as a healthcare provider?

How to Explain a DNR Order to the Family

When explaining a DNR order to a family, frame the conversation around the patient's values and goals of care, emphasizing that DNR means "do not attempt resuscitation" when the heart or breathing stops, while clarifying that all other appropriate medical care and comfort measures will continue unless specifically refused. 1, 2

Prepare for the Conversation

Understand Your Legal and Ethical Framework

• Recognize that DNR decisions are ethically supportable when the burdens of treatment outweigh the benefits to the patient 1
• Ensure you understand your state's specific regulations and institutional policies regarding DNR orders 1, 2
• A licensed physician's order is legally necessary to withhold CPR in the hospital setting, and oral DNR orders are not acceptable—they must be written 2

Gather the Right People

• Identify the appropriate decision-maker (the patient if capable, or the legally authorized surrogate/medical power of attorney if not) 3
• Verify the surrogate's legal authority and ensure they understand their responsibility to make decisions based on the patient's known values, goals, and preferences 3
• Consider having a support person present (nurse, chaplain, social worker) to assist the family during this difficult conversation 1

Structure the Conversation

Start with Understanding, Not the Order

• Begin by exploring what the patient/family understands about the current medical situation and prognosis 3
• Use open-ended questions like "What is your understanding of how your loved one is doing?" 3
• Share information in small amounts, using language appropriate to the family's health literacy, and check understanding frequently 3

Clarify the Patient's Values and Goals

• Ask what makes life meaningful to the patient, what their priorities are, and what they fear 3
• Explore the patient's previously expressed values during periods of capacity if applicable 3
• Address how culture, religion, or spiritual belief systems affect their end-of-life decision-making 3

Explain What DNR Actually Means

Use clear, specific language:

• Consider using "Do Not Attempt Resuscitation" (DNAR) rather than DNR, as it reduces the false implication that resuscitation is likely to succeed and creates a better emotional environment 4
• In some settings, "Allow Natural Death" (AND) may be even clearer for families to understand 4

Be explicit about what will NOT be done:

• Chest compressions will not be performed 2
• Endotracheal intubation and mechanical ventilation will not be initiated 2
• Vasopressors for cardiac arrest will not be administered 2
• Defibrillation will not be attempted 2

Emphasize what WILL continue:

• All other appropriate medical treatments will continue unless specifically refused 2, 5
• Supplemental oxygen, intravenous fluids, pain management, and antibiotics may all continue 2
• Comfort measures and nursing care will be maintained 5
• The patient will not be abandoned—aggressive symptom management and palliative care will be provided 5

Address Common Misconceptions

Critical pitfall to avoid: Families often misunderstand DNR as meaning "do nothing" or withdrawal of all care 6, 7

• Explicitly state that DNR orders do not affect other treatments unless specifically noted 2
• Clarify that DNR is a specific medical order about CPR only, not an advance directive that limits all care 2
• Explain that the order can be reviewed and modified if the patient's condition or wishes change 2

Facilitate Shared Decision-Making

Present the Medical Reality

• Provide truthful information about the likelihood of successful resuscitation given the patient's specific condition 1, 7
• Explain what to expect as the disease progresses 3
• Discuss which goals and preferences for future treatment are realistic given the medical situation 3

Support the Family Through Conflict

• Acknowledge and address emotions throughout the conversation 3
• If there is disagreement among family members or between family and medical team, use basic principles of negotiation and conflict resolution 1
• Consider involving palliative care consultants or ethics consultation when ethical concerns arise or require clarification 1

Allow Time, But Not Prolonged Suffering

• Reasonable accommodation for timing may be given to families to allow family members to gather 1
• However, exercise utmost care to avoid prolonging suffering of the patient 1

Document Thoroughly

Required Documentation Elements

• Patient's capacity at the time of decision-making and date of DNR implementation 2
• Record of discussion with patient and/or surrogate decision-maker, including the patient's values, goals, and preferences 2
• Specific interventions to be withheld 2
• Rationale for the DNR order 2
• Patient or surrogate signature (if capable) and witness signatures 2
• Statement indicating when the order should be reviewed 2

Special Considerations

Perioperative DNR Orders

• DNR orders may remain in effect during surgery if consistent with the patient's goals of care 1, 2
• The order should be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate 2

When Family Disagrees with Medical Team

• In rare circumstances of extreme burden of treatment with no benefit beyond postponing death, it may be ethically supportable to forgo life-sustaining treatment without family agreement 1
• This should only occur after exhausting conflict resolution strategies and obtaining ethics consultation 1

Review and Renewal

• DNR orders should be reviewed periodically per local protocol, particularly if the patient's condition changes 2
• The process for revoking or modifying the order should be clearly explained to the family 2