Why do not resuscitate

Overview

Do Not Resuscitate (DNR) orders emerged as a response to the development of modern cardiopulmonary resuscitation (CPR) techniques in the 1960s. Before CPR became widely available, death was typically accepted when breathing and heartbeat ceased naturally. The introduction of effective CPR created ethical dilemmas about when resuscitation attempts should be made. In 1974, the American Heart Association published guidelines for CPR, which included discussions about when not to resuscitate. By 1976, the first formal DNR policies appeared in hospitals, with Massachusetts General Hospital implementing one of the earliest standardized protocols. These orders gained legal recognition throughout the 1980s and 1990s, with all 50 U.S. states now having laws governing DNR orders. The concept has evolved to include various forms such as DNR Comfort Care orders, which allow for palliative treatments while prohibiting CPR.

How It Works

A DNR order is typically initiated through a conversation between the patient (or their legal surrogate) and their healthcare provider. The process begins with a discussion about the patient's medical condition, prognosis, and treatment preferences. If CPR would be medically futile or inconsistent with the patient's goals, the provider may recommend a DNR order. The order must be documented in the patient's medical record and is usually signed by both the physician and patient/surrogate. In hospital settings, DNR orders are often indicated with specific colored forms or wristbands to alert staff quickly. For out-of-hospital settings, many states have standardized forms like the Physician Orders for Life-Sustaining Treatment (POLST) that travel with the patient. The order specifically applies only to CPR attempts - other treatments like antibiotics, pain management, or feeding tubes may continue unless otherwise specified. Healthcare providers must verify the order's validity and ensure all team members are aware of it during emergencies.

Why It Matters

DNR orders matter because they respect patient autonomy and prevent unwanted medical interventions. Without a DNR order, healthcare providers are legally obligated to attempt CPR, which can cause broken ribs, brain damage, or prolonged suffering for patients with terminal conditions. Studies show that CPR success rates for hospitalized patients with multiple chronic illnesses are less than 10%, making DNR orders a realistic approach to end-of-life care. These orders also reduce healthcare costs by avoiding expensive, futile interventions - one study estimated that inappropriate CPR attempts cost the U.S. healthcare system over $1 billion annually. DNR discussions encourage important conversations about treatment goals and help families make informed decisions during medical crises. They are particularly significant for elderly patients, with research indicating that patients over 85 with DNR orders have better quality end-of-life care compared to those without such directives.