A “do not resuscitate” (DNR) order indicates that a person — usually with a terminal illness or other serious medical condition — has decided not to have cardiopulmonary resuscitation (CPR) attempted in the event his or her heart or breathing stops. In most situations, a DNR order is written by a physician after discussing the burdens and benefits of CPR with the patient or the patient’s surrogate decision maker.
Why would a person sign such an order?
At some point for late stage terminally ill patients, CPR will not be life-saving, and will only cause harm. If the physicians caring for you or your loved one believe strongly that this is the case, they will discuss with you why it is not being offered as an option. Various methods of CPR often involve more than chest compressions and mouth-to-mouth resuscitation. CPR also might include the use of powerful drugs or electric shock to start the heart beating again, or might require the insertion of a breathing tube. Although CPR can save lives, it frequently does not work. Even if a person is resuscitated, he or she might suffer painful injuries during CPR or might be left in a worse condition than before. Also, people with terminal illnesses or other serious medical conditions might not want to have CPR performed on them, even if that means they might die as a result.
Some people believe that CPR offers hope. Such hope, however, is not useful if there’s no chance of restoring heart function. The resuscitation procedure is complex, costly, labor intensive (involving many health care providers), and causes physical damage to the patient. Such a demanding procedure should not be performed when there’s no chance of success.
Physicians are not obliged to provide treatment that can’t possibly work, and the ethics of doing so are questionable. For example, a surgeon can’t be expected to perform surgery that has no chance of success; a physician can’t be obliged to prescribe medication whose use is not supported by evidence.
If you or a loved one are facing a life limiting condition, chances are that you will be asked to sign a DNR order at some point. My father was asked to sign a DNR order for my Mom, who had late stage liver disease. The doctor explained it as deciding not to perform heroic measures in an attempt to restart the heart and breathing, as attempts to restore heart function in a person dying from a progressive terminal condition rarely work and often just cause damage. It is difficult but important to understand that cardiopulmonary resuscitation (CPR) rarely works in these circumstances because the heart has stopped from the burden of illness on the entire body and not due to a problem with the heart itself.
Discussing resuscitation decisions can be very difficult. Often if feels unnatural not to do anything and everything to prolong life. Open and honest communication with the medical team is essential, as are having all the facts.
It is not honest to offer CPR as an intervention that offers hope in the end stages of a terminal illness, and therefore, it may not be offered by your physician. If there is a disagreement among the patient, their family and the health care team, it would be a good idea to obtain a second opinion from another physician. If the second physician doesn’t support the first physician’s decision, then care may be transferred to the second physician.
Finally, remember that CPR is a vigorous emergency procedure and it is not always successful. Experience has shown that CPR does not restore breathing and heart function in patients who have widespread cancer, widespread infection or other terminal illness.
Please share your thought on DNR orders in the comments below.