What Does a Do-Not-Resuscitate (DNR) Order Mean and Why Are They Used?
Key takeaways:
A do-not-resuscitate (DNR) order is a legal order that tells healthcare personnel that you don’t want lifesaving treatment if your heart or lungs can no longer support you on their own.
DNR orders are more common among people with a terminal condition, or whose chance of surviving resuscitation is very low.
DNR orders go into effect if your heart stops beating. They fall under the umbrella of advance care planning, which allows you to specify the medical care you want to receive when you can’t make decisions for yourself.
Table of contents
Most people have only ever seen CPR (cardiopulmonary resuscitation) when it’s performed on television and in movies. And this causes people to overestimate its effectiveness. In reality, survival rates are only 10% to 20% for people who have a cardiac arrest outside the hospital. This number is even lower in those with several chronic health conditions and terminal illnesses. So, many people in these circumstances choose to get a do-not-resuscitate order (DNR order) to avoid getting CPR if their heart were to stop beating.
If you or a loved one is considering a DNR order, the process and medical terms can get confusing. So, we will walk you through exactly what a DNR means for someone and their medical care.
What is a DNR?
A DNR order is a legal document signed by you and a healthcare professional. It tells emergency responders and other medical personnel not to perform CPR if your heart stops (also called a cardiac arrest) or you stop breathing.
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CPR includes:
Chest compressions (pressing on the chest to keep blood flowing)
Electricity (a defibrillator) or medications to try and restart the heart
Breathing support, which can include things like mouth-to-mouth breathing, oxygen, or a mask and inflatable bag
Even though most people use the term DNR, the medical community sometimes prefers the following terms instead:
Do not attempt resuscitation (DNAR): This term is preferred by the American Heart Association because it reinforces the idea that resuscitation isn’t always successful. It removes the false expectation that CPR can always save someone’s life.
Allow natural death (AND): This term is preferred by the Hospice Patients’ Alliance
because it reinforces the idea that someone isn’t choosing death, but rather letting nature take its course.
What does resuscitate mean?
Resuscitation is a medical term that refers to any treatment or action taken to save someone’s life. It can include treatments for someone who:
Is in cardiac arrest (their heart has stopped)
Has stopped breathing or is having severe trouble breathing
Is unconscious
Is conscious but is critically ill and near death
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This means it can include many treatments beyond CPR. It can include procedures like intubation, which is when someone is placed on a ventilator (or life support machine). It can also include many different types of medications, from intravenous (IV) fluids to antibiotics.
It’s important to note that a DNR order doesn’t prevent someone from receiving other treatments that fall under the category of “resuscitation.” For example, someone might not want CPR but still want breathing support; this decision can be separate. And someone who has a DNR order can still receive medications like antibiotics.
Is DNR good or bad?
A DNR order is neither good nor bad. It’s a personal decision that takes into account someone’s current health status, prognosis, and priorities for their medical care. It’s important not to place judgment on their decision. It’s also important to remember that a DNR order doesn’t mean someone is choosing death. Instead, it allows someone to choose how they want to live at the end of their life.
What does CPR actually mean? A DNR order means you don’t want CPR. But few people know exactly what CPR includes and when it’s used.
End-of-life planning checklist: It can be overwhelming to plan for your or a loved one’s death. But this checklist will walk you through it.
Emergency contact list: It’s important to create an emergency contact list, so that others can communicate your health history and wishes for your medical care.
Does every U.S. state allow DNR orders?
Every state allows DNR orders, but there are differences in state laws. For example:
Some states use different terms. Examples include a do not attempt resuscitation (DNAR) order, a no code order, and an allow natural death (AND) order.
There are different laws around who can sign the order. In some states, it needs to be a physician. In other states, a nurse practitioner (NP) or physician associate (PA) can sign it.
Some states require a notary signature or two witnesses to be present at signing.
Since DNR orders are state-specific, they must be updated if you move to a different state. So if you move from California to Texas, for example, a new DNR order would need to be signed. When traveling to another state, most states have provisions to honor someone’s home state DNR orders. But since these provisions vary from state to state, it’s best to travel with documentation and look into other states’ laws before you go.
Why would someone get a DNR?
People choose to have a DNR order for different reasons. Many times, people or their family members file DNR orders when there’s a lower chance that CPR will save their life when their heart stops beating.
Some instances where a person would consider a DNR order include:
A short time left to live because of a terminal illness
Serious chronic illnesses, such as congestive heart failure or COPD
Decreasing quality of life or increasing dependence on others for basic daily needs
But there are many additional factors that play a role in someone’s decision to get a DNR. Not everyone chooses to get one because they have a terminal or advanced illness. For example, spiritual and religious beliefs often play a role in people’s preferences. And some people simply don’t want to be on life support at the end of their days, so they choose a DNR order to prevent that.
How is a do-not-resuscitate order created?
There are a few different ways you can create a DNR order. The best place to start is to have a conversation with your primary care provider or a healthcare professional you know and trust. The next step depends on your particular situation, and where you are in your end-of-life planning.
If you aren’t currently hospitalized and you would simply like to create a DNR, your healthcare professional can point you towards the required forms. You can also find this information on your state website. Again, each state has different specifications to make the document official.
But there are many other options to file a DNR order, which also allow you to specify other wishes or directives for your end-of-life care.
Physician order for life-sustaining treatment (POLST)
A DNR order allows you to choose whether or not you want CPR in an emergency. It doesn’t give instructions for other treatments, such as artificial nutrition, IV fluids, or antibiotics.
Many states have adopted another set of orders called the Physician Orders for Life-Sustaining Medical Treatment (POLST). The POLST is more detailed than a DNR order. It includes different options for CPR and details on what kind of treatments you want as part of your medical care. The POLST can have different names depending on where you live.
Advance directive
An advance healthcare directive, or advance directive, is a legal document that details a person’s wishes for their future medical care. Even if you don’t have medical issues now, an advance directive can help you when you have a serious health condition and can no longer make decisions for yourself. It goes into effect if you aren’t able to express these wishes on your own.
An advance directive specifically refers to a combination of two main documents: a living will and a durable power of attorney for healthcare (or medical power of attorney).
A living will
A living will explains the type of treatment you would want if you were nearing the end of your life but unable to make or communicate your decisions. (Note that it’s not the same as a last will, which describes who will inherit your property and assets after you die.)
A living will gives more detailed information about medical care such as:
CPR and defibrillation (the same treatment covered under a DNR order)
A breathing machine (also called a ventilator)
Artificial nutrition, like the type of nutrition delivered through a feeding tube or IV
Dialysis
Emergency surgery
Medicines and blood transfusions
Organ and tissue donation
There are a few important things to note about a living will:
A DNR request in your living will isn’t the same as a DNR order. You must still communicate your DNR request to your primary care provider, who can then enter a DNR order in your medical record.
Before a living will can be used to guide your healthcare, two physicians have to confirm that you’re no longer able to make decisions. It’s also required that your medical condition can’t be cured or you’re permanently unconscious.
Durable power of attorney for healthcare
A durable power of attorney (DPOA) names a person you choose to make medical decisions for you if you can’t communicate your wishes. Your medical team will use your living will to guide your medical care, but your DPOA will make decisions about anything not covered in your living will.
Note that a DPOA has many other names:
Health care proxy
Healthcare power of attorney
Surrogate
Comparing an advance healthcare directive, POLST, and DNR
All three end-of-life planning documents guide some aspect of your medical care. But the chart below can help you understand the main differences.
Advance healthcare directive | POLST | DNR order | |
|---|---|---|---|
Is it a legal document? | Yes | Yes | Yes |
Who typically fills one out? | Any adult | Terminally ill persons, older adults, those with advanced chronic disease | Terminally ill persons, older adults, those with advanced chronic disease |
Who is it completed and signed by? | An attorney | A physician | A physician |
How long is the document? | Several pages | Usually one to two pages | Usually one to two pages |
Can you name a healthcare POA? | Yes | No | No |
Is it used by first responders (i.e., paramedics)? | No | Yes | Yes |
Is it in your medical record? | No | Yes | Yes |
Are there circumstances where medical personnel will resuscitate a person even with a DNR order?
Depending on state laws, medical personnel may still resuscitate a person with a DNR order if:
There’s no written documentation of the DNR order.
They can’t find or confirm the DNR order.
There’s a question whether the DNR is valid.
The cause of the heart or breathing stopping is from something unnatural, like trauma or a sudden blockage in the airway.
Most states have options for people to wear jewelry that indicates that there’s a DNR order. But it’s important to check with your state laws to know what type of identification is valid. It’s also important to know if the jewelry can work in place of a physical DNR order and which jewelry makers are approved by your state.
If there’s any doubt, medical professionals will err on the side of resuscitation. So, if you sign a DNR order, be sure your family knows your wishes and where to find the forms.
Can a family refuse a DNR order?
If a person has already completed a DNR order, their family can’t refuse the order. If you have a DNR order and your family members disagree, medical personnel will still honor your wishes. And the medical staff will work with your family to help them understand your decision.
The bottom line
A DNR order specifies that someone doesn’t want CPR in an emergency. It’s one decision of many that are important to think about for end-life-care. Additional advance care planning documents can offer more detail about someone’s wishes for their medical care if they’re very sick, have a terminal or advanced illness, or are nearing the end of their life. But you don’t have to do this planning alone. Your family, friends, and medical care team can help you with these hard but important decisions.
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References
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American Heart Association. (n.d.). CPR facts and stats.
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Brealt, J. L. (2011). DNR, DNAR, or AND? Is language important? The Ochsner Journal.
Free Will. (2021). Last will vs. living will: What’s the difference?
Institute for Healthcare Improvement. (n.d.). Your guide to choosing a health care proxy.
Marie Curie. (2022). What is a terminal illness?
National Physician Orders for Life-Sustaining Treatment. (n.d.). POLST program names.
Pope, T. M. (2023). Do-not-resuscitate (DNR) orders. Merck Manual.
Portnova, J., et al. (2015). It isn’t like this on TV: Revisiting CPR survival rates depicted on popular TV shows. Resuscitation.
Sehatzadeh, S. (2014). Cardiopulmonary resuscitation in patients with terminal illness: An evidence-based analysis. Ontario Health Technology Assessment Series.
Texas Health and Human Services. (n.d.). Out of hospital do not resuscitate program.
Walter, K. (2021). Durable power of attorney for health care. Journal of the American Medical Association.
