A “do not resuscitate” order instructs medical workers in and outside of a hospital not to restart your heart if it stops. It prohibits CPR and associated resuscitative measures, including electrical shocks to the heart, intubation, ventilation and certain medications.
A D.N.R. can be a powerful way to communicate your wishes, yet some studies show that medical workers sometimes override them and resuscitate patients who have one. Other research suggests that D.N.R.s sometimes get misinterpreted as “do not treat,” and medical workers may incorrectly assume that patients with D.N.R. orders don’t want other lifesaving interventions, like dialysis or treatments in the intensive care unit.
Here’s what to know and how to increase the likelihood that your wishes are upheld.
Why consider a D.N.R.?
If you are sick or frail, the harms of CPR “significantly outweigh the benefits,” said Mathew Pauley, a bioethicist at the Kaiser Permanente hospital system in California. Even if CPR revives you, which research shows is unlikely, chest compressions and shocks can cause debilitating injuries like broken bones, punctured lungs and burns. Some who survive CPR have lasting cognitive impairments because of oxygen deprivation.
People with D.N.R.s tend to be older adults with serious health conditions. In a 2011 study in Canada, some D.N.R. patients wanted to avoid resuscitation because their quality of life was already low or because they feared resuscitation would lower it even more. Others wanted to minimize the emotional and financial burden on their families as well as the costs to society. Some D.N.R. patients said they wanted to die naturally when their time came.
How to ensure your wishes are upheld
Talk to your doctor and select a form.
Whatever your reasons for considering a D.N.R., communicate your priorities, logic and expectations to your medical providers, said Dr. Max Vergo, a palliative care doctor for Dartmouth Health in New Hampshire. Start with a clinician who sees you regularly. Medicare covers advance care planning costs during annual checkups.
That person can explain how medical interventions may affect your body and advise if a D.N.R. makes sense. If so, your doctor can provide the form, which you both will need to sign to make it valid.
A D.N.R. form isn’t your only option. Experts like Dr. Vergo recommend that instead of D.N.R. orders, patients fill out POLST forms. (This stands for “physician orders for life-sustaining treatment,” though the forms can have other names).
These forms allow for more detail and clarity around your care. You can state more specifically what treatments you do and do not want to receive — including CPR, as well as intubation, defibrillation, ventilation, nutrition and fluids, antibiotics and comfort measures.
Ask the doctor who signed off on your POLST to write a note to accompany the form describing what’s important to you. This documentation of your goals is invaluable, Dr. Vergo said, especially in an unexpected medical situation.
If you’re preparing for surgery, your doctors may want to suspend your D.N.R. or part of your POLST while you’re in the operating room. This allows them to address problems that might cause your heart to stop — like an allergic reaction to medication — but are easily reversible and unlikely to impact your quality of life. But whether they suspend, limit or leave those orders in place is ultimately up to you.
Prepare your forms — and your family.
D.N.R.s and POLSTs often go into effect in emergencies, when it might be difficult for medical workers to see your forms. Attach a copy to the refrigerator, where paramedics are trained to look. You can also stick a decal on your front door or window. D.N.R. bracelets, which are imprinted with “do not resuscitate” or “POLST,” indicate that you have a form filled out. But in some states, if you have the bracelet but not the form, emergency medical workers may ignore the directive.
“You have to get really comfortable talking about your wishes,” said Jennifer Pardini, a community educator at Legal Assistance for Seniors in Oakland, Calif. Don’t let your care decisions remain a mystery, especially to loved ones. Tell them where your forms are, and, if possible, give them copies.
If you change doctors, go to the hospital or move into long-term care, bring your forms. Even if your doctor entered your D.N.R. or POLST into your electronic health record, information isn’t always shared between doctors and facilities. Be prepared to have these conversations multiple times with multiple providers, Ms. Pardini said. The more people who know about your wishes, the lower the chance of confusion.
Your decisions about your care may evolve after a change in health status. If you decide to revoke or modify your D.N.R. or POLST, talk with your doctor and family, destroy all copies of your old forms and, if applicable, fill out new ones. A D.N.R. or a POLST is intended to protect you, Dr. Vergo said: “It’s not designed to be some sort of handcuff.”
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