Validity of DNR Orders from Another Institution
DNR orders from another institution are NOT automatically valid and must be rewritten by a physician at the receiving hospital according to local policy. 1
Key Principle: DNR Orders Require Physician Documentation at Each Institution
The American Heart Association guidelines are explicit that a licensed physician's order is necessary to withhold CPR in the hospital setting, and this order must be written in accordance with local policy in the patient's chart. 1 This means:
- Oral DNR orders are not acceptable 1
- The attending physician must write the DNR order with a note explaining the rationale, specific limitations of care, and documentation of discussions with the patient, surrogate, and family 1
- The order must be written according to the local policy of the receiving institution 1
What Happens During Transfer
When a patient with a DNR order is transferred to another hospital:
- The DNR status should be communicated during the transfer process, but this does not constitute a valid order at the new institution 2
- A new DNR order must be written by a physician at the receiving hospital following their institutional protocols 1
- The receiving physician should review the patient's advance directives, discuss with the patient or surrogate, and document a new order per local policy 1
Critical Distinction: Advance Directives vs. DNR Orders
It's important to understand that:
- Advance directives (living wills, healthcare proxies) remain valid across institutions and should guide DNR decision-making 1
- DNR orders are institution-specific medical orders that must be rewritten 1
- The patient's wishes documented in advance directives should inform the new DNR order at the receiving facility 1
Common Pitfall to Avoid
Do not assume the DNR order automatically transfers. Without a properly documented DNR order at the receiving institution, CPR is presumed to be consented to by default, and resuscitation would be initiated in the event of cardiac arrest. 3 This could result in unwanted aggressive interventions that contradict the patient's documented wishes.
Practical Approach
Upon receiving a transferred patient with DNR status:
- Immediately review any advance directives or documentation of the patient's wishes 1
- Discuss with the patient or surrogate to confirm their current preferences 1
- Write a new DNR order according to your institution's policy within the first hours of admission 1
- Document explicitly which interventions are withheld and which continue 1
The correct answer is C) DNR from another institution is not valid - it must be rewritten at the receiving hospital.