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ETHICS IN MEDICINE   University of Washington School of Medicine
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Do Not Resuscitate (DNAR) Orders

Clarence H. Braddock III, MD, MPH (1998)
Jonna Derbenwick Clark, MD, MA

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Case 3


What is a Do Not Attempt Resuscitation (DNAR) Order?

A Do Not Attempt Resuscitation (DNAR) Order, also known as a do not resuscitate (DNR) order, is written by a licensed physician in consultation with a patient or surrogate decision maker that indicates whether or not the patient will receive cardiopulmonary resuscitation (CPR) in the setting of cardiac and/or respiratory arrest. CPR is a series of specific medical procedures that attempt to maintain perfusion to vital organs while efforts are made to reverse the underlying cause for the cardiopulmonary arrest. Although a DNAR order may be a component of an advance directive or indicated through advance care planning, it is valid without an advance directive. (See Advance Care Planning and Advance Directives)

History of Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Orders

The history of CPR and DNAR orders is extensively reviewed in the literature (Bishop et al., 2010; Burns et al., 2003). In the 1960s, CPR was initially performed by anesthesiologists on adults and children who suffered from witnessed cardiac arrest following reversible illnesses and injuries. Based on the success of this intervention, CPR became the standard of care for all etiologies of cardiopulmonary arrest and the universal presumptive consent to resuscitation evolved (Burns et al., 2003). However, in 1974, the American Heart Association (AHA) recognized that many patients who received CPR survived with significant morbidities and recommended that physicians document in the chart when CPR is not indicated after obtaining patient or surrogate consent (ibid). This documentation formally became known as the DNR order. Recent medical literature encourages reference to this documentation as do-not-attempt-resuscitation (DNAR) and allow a natural death (AND) based on the practical reality that performing CPR is an attempt to save life rather than a guarantee (Venneman et al., 2008).

The Role of Patient Autonomy

Since the original inception of DNAR orders, respecting the rights of adult patients and their surrogates to make medical decisions, otherwise known as respect for autonomy or respect for persons, has been emphasized. This concept is reinforced legally in the Patient Self Determination Act of 1991, which requires hospitals to respect the adult patient’s right to make an advanced care directive and clarify wishes for end-of-life care. In general, an emphasis on improving communication with patients and families is preferred over physicians making unilateral decisions based on appeals to medical futility regarding the resuscitation status of their patients. See below.

What if patients are unable to express what their wishes are?

In some cases, patients are unable to participate in decision-making, and hence cannot voice their preferences regarding cardiopulmonary resuscitation. Under these circumstances, two approaches are used to ensure that the best attempt is made to provide the patient with the medical care they would desire if they were able to express their voice. These approaches include Advance Care Planning and the use of surrogate decision makers. (See Advance Care Planning and Advance Directives , and Surrogate Decision Makers)

Not all patients have Advance Care Plans. Under these circumstances, a surrogate decision maker who is close to the patient and familiar with the patient’s wishes may be identified. Washington state recognizes a legal hierarchy of surrogate decision-makers, though generally close family members and significant others should be involved in the discussion and ideally reach some consensus. Not all states specify a hierarchy, so check your state law. Washington’s hierarchy is as follows:

    1. Legal guardian with health care decision-making authority
    2. Individual given durable power of attorney for health care decisions
    3. Spouse
    4. Adult children of patient (all in agreement)
    5. Parents of patient
    6. Adult siblings of patient (all in agreement)

The surrogate decision maker is expected to make decisions using a substituted judgment standard, which is based on what the patient would want if she could express her wishes. In certain circumstances, such as in children who have not yet developed decisional capacity, parents are expected to make decisions based on the best of the patient, called a best interest standard.

When should CPR be administered?

In the absence of a valid physician’s order to forgo CPR, if a patient experiences cardiac or respiratory arrest, the standard of care is to attempt CPR. Paramedics responding to an arrest are required to administer CPR. Since 1994 in Washington, patients may wear a bracelet or carry paperwork that allows a responding paramedic to honor a physician's order to forgo CPR. In the state of Washington, the POLST form is a portable physician order sheet that enables any individual with an advanced life-limiting illness to effectively communicate his or her wishes to limit life-sustaining medical treatment in a variety of health care settings, including the outpatient setting (Washington State Medical Association ).

Is CPR always beneficial?

The general rule of attempting universal CPR needs careful consideration (Blinderman et al., 2012). Even though including patients and families in decisions regarding resuscitation respects patient autonomy, providing patients and families with accurate information regarding the risks and potential medical benefit of cardiopulmonary resuscitation is also critical. Under certain circumstances, CPR may not offer the patient direct clinical benefit, either because the resuscitation will not be successful or because surviving the resuscitation will lead to co-morbidities that will merely prolong suffering without reversing the underlying disease. Some physicians and ethicists define CPR under these circumstances as medically inappropriate or “futile” (Burns & Truog, 2007). Hence, evaluating both the proximal and distal causes of the cardiac arrest is important when determining the likelihood of successful resuscitation (Bishop et al., 2010; Blinderman et al. 2012). When CPR does not have the potential to provide direct medical benefit, physicians may be ethically justified in writing a DNAR order and forgoing resuscitation.

Defining Direct Medical Benefit

Determining the potential for direct medical benefit can be challenging, especially when there is great uncertainty in outcome. One approach to defining benefit examines the probability of an intervention leading to a desirable outcome. Outcomes following CPR have been evaluated in a wide variety of clinical situations. In general, survival rates in adults following in-hospital cardiac arrest range from 8-39% with favorable neurological outcomes in 7-14% of survivors (Meaney et al., 2010). In children, the survival rate following in-hospital cardiac arrest is closer to 27% with a favorable neurological outcome in up to one third of survivors (AHA, 2010). Out of hospital arrest is less successful, with survival rates in adults ranging from 7-14% and in infants and children approximately 3-9% (Meaney et al., 2010; Garza et al., 2009). In general, these statistics represent the population as a whole and do not necessarily reflect the chance of survival for an individual patient. Hence, multiple factors, including both the distal and proximal causes for cardiopulmonary arrest, must be considered to determine whether or not CPR has the potential to promote survival (Bishop et al., 2010).

How should the patient's quality of life be considered?

CPR might appear to lack potential benefit when the patient's quality of life is so poor that no meaningful survival is expected even if CPR were successful at restoring circulatory stability. However, quality of life should be used with caution in determining whether or not CPR is indicated or has the potential to provide medical benefit, for there is substantial evidence that patients with chronic conditions often rate their quality of life much higher than would healthy people. Quality of life assessments have most credibility when the patient’s values, preferences, and statements inform such assessments.

When can CPR be withheld?

Many hospitals have policies that describe circumstances under which CPR can be withheld based on the practical reality that CPR does not always provide direct medical benefit. Two general situations justify withholding CPR:

  • When CPR will likely be ineffective and has minimal potential to provide direct medical benefit to the patient.
  • When the patient with intact decision making capacity or a surrogate decision maker explicitly requests to forgo CPR.

How are DNAR Orders Written?

Prior to writing a DNAR Order, physicians should discuss resuscitation preferences with the patient or his/her surrogate decision maker (Blinderman et al., 2012; Quill et al., 2009). This conversation should be documented in the medical record, indicating who was present for the conversation, who was involved in the decision making process, the content of the conversation, and the details of any disagreement.

These conversations are difficult and involve a careful consideration of the potential likelihood for clinical benefit within the context of the patient's preferences. Physicians can most effectively guide the conversation by addressing the likelihood of direct benefit from cardiopulmonary resuscitation within the context of the overall hopes and goals for the patient. They can then partner with the patient and his or her family to determine the clinical interventions that most effectively achieve these goals (Blinderman et al., 2012). This approach is described by the palliative care literature as a goal oriented approach to providing end of life care.

If CPR is deemed "futile," should a DNAR order be written?

If health care providers unanimously agree that CPR would be medically futile, clinicians are not obligated to perform it. Nevertheless, the patient and/or their family still have a role in the decision about a Do Not Attempt Resuscitation (DNAR) order. As described earlier, involving the patient or surrogate decision maker is essential to demonstrate respect for all people to take part in important life decisions.

In many cases, patients or surrogate decision makers will agree to forgo attempting CPR following a transparent and honest discussion regarding the clinical situation and the limitations of medicine. Under these circumstances, DNAR orders can be written. Each hospital has specific procedures for writing a valid DNAR order.

What if CPR is not futile, but the patient wants a DNAR order?

In some cases, patients may request their desire to forgo attempting CPR at the time of admission. Some of these patients may have an advanced care directive that indicates their preferences to forgo attempting CPR. In other cases, a patient may explicitly request CPR not to be performed. If the patient understands her condition and possesses intact decision making capacity, her request should be honored. This position stems from respect for autonomy, and is supported by law in many states that recognize a competent patient's right to refuse treatment.

What if the family disagrees with the DNAR order?

Ethicists and physicians are divided over how to proceed if the family disagrees with the recommendation to forgo attempting CPR.

If there is disagreement, every reasonable effort should be made to clarify questions and communicate the risks and potential benefits of CPR with the patient or family. In many cases, this conversation will lead to resolution of the conflict. However, in difficult cases, an ethics consultation can prove helpful.

What about "slow codes" or “show codes”?

Slow codes and show codes are forms of “symbolic resuscitation.” A “slow code” is an act performed by the health care providers that resembles CPR yet is not the full effort of resuscitation while a “show code” is a short and vigorous resuscitation performed to benefit the family while minimizing harm to the patient (Frader et al., 2010). Slow and show codes are ethically problematic. In general, performing slow and show codes undermines the rights of patients to be involved in clinical decisions, is deceptive, and violates the trust that patients have in health care providers.

Special Circumstances

There are special circumstances that should be considered and addressed in patients with Do Not Attempt Resuscitation Orders. These circumstances primarily arise when a patient undergoes anesthesia for surgical interventions or requires urgent procedures. (See Do Not Resuscitate Orders during Anesthesia and Urgent Procedures)


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Case studies: Case 1 | Case 2 | Case 3

Related Discussion Topics/Links: DNR Orders during Anesthesia and Urgent Procedures, Futility, Respect for Autonomy, Advance Care Planning, Advance Directives

Core clerkship material: Family Medicine | Internal Medicine | Anesthesiology | Surgery


Clarence H. Braddock III, MD, MPH
Professor, Department of Medicine, Stanford University
Associate Dean for Undergraduate and Graduate Medical Education

Jonna Derbenwick Clark, MD, MA (Bioethics)
Staff Pediatrician, Seattle Children's Hospital
Assistant Professor, UW Pediatrics

 

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Last date modified: September 4, 2014