PhD, MS, MSN, APRN-BC, CCRN, CDCES, CNE, COI
What is a DNR? A Do-not-resuscitate order, also known as a DNR order, is a written legal document clarifying resuscitation preferences by an individual.
Goldman-Cecil Medicine Volume 2 goes on to say “it instructs healthcare professionals to deliver basic and advanced cardiac life saving measures or withhold from providing CPR when the person’s heart stops based on the patient’s wishes.”
The default medical action for a cardiac or respiratory arrest is to provide standard basic and advanced life saving measures unless directed otherwise. Ideally it is written before an emergency that threatens a person’s life.
It is a legal document and must be witnessed by another adult such as a spouse, adult child, guardian, adult sibling, or friend. It only specifies the act of cardiopulmonary resuscitation and no other medical or palliative procedures such as delivering pain management, IV fluids or nutrition to sustain life.
Nurses need to know what is a DNR, how it is created, who can sign it, and what their responsibility is regarding a DNR order.
Ideally it is a legal document and found in the patient’s medical chart. Unfortunately, many times a written and signed order is hard to locate and without it, the medical team is legally and medically responsible to provide life saving measures when a patient’s heart stops.
Some facilities have a policy that a nurse who is caring for the client cannot be one of the witnesses, but that varies among facilities.
Every time a person is admitted to a hospital, including an ER visit, nurses should ask if the person has a living will, or advance directives.
Advance directives is an umbrella term for legal forms that direct the medical staff in advance of a client’s inability to voice a preference for end-of-life procedures due to an injury or serious illness.
Three forms are included under advance directives and include the DNR form, the living will, and durable power of attorney. The DNR form states the person’s desire for or against cardiopulmonary resuscitation. The living will is a general term voicing the person’s preferences.
An example of a common statement found in a living will is: “If I suffer an incurable, irreversible illness, disease, or condition and my attending physician determines that my condition is terminal, I direct that life-sustaining measures that would serve only to prolong my dying be withheld or discontinued.” The durable power of attorney for medical decisions names someone to make decisions for them if the person is unable to do so.
The role of the nurse is to follow the wishes of the client based on the legally signed document and bring it to the attention of the provider and medical team. The challenge becomes when the document cannot be located, or the patient changes his mind.
Nurses have heard the stories, or even witnessed the event of a “slow code” when the nurse knows the patient doesn’t want to be resuscitated but there is a scramble to find the actual document to confirm the patient’s desire while they are in cardiac arrest.
A verbal order can be given for a DNR and medical procedures, but it must be signed by both the nurse receiving the verbal order and the physician within 24 hours of giving the order.
As a patient advocate, the nurse often helps educate the patient and family members about expected outcomes to help them make decisions. However, it is not the legal responsibility of the nurse to declare a diagnosis or prognosis. Letting the physician know there may be a conflict or misunderstanding by the patient is the role of the nurse.
There is currently no standard law or agreed upon medical practice to address the permanent ink request. Each time someone presents with a DNR tattoo, medical personnel must scramble to find a legal document to confirm the wishes.
Even people without a DNR tattoo must produce documents, which can be difficult to locate in an emergency. The issue is that healthcare providers take life and death situations seriously, rightfully so.
One suggestion is to have an online electronic software registry that recognizes face and fingerprints to confirm the authenticity of a living will and advance directives. Even having a video of the person stating their preference may be more effective in today’s era of internet hacking and changing passwords if an inheritance were at risk!
The role of nurses in following a tattooed DNR is unsure as the medical community still is grappling with the legal and ethical factors of this issue. If you or you patient wants to get a DNR tattoo, just follow that with a written and legally witnessed document that is filed in an easy to obtain location. Bring a copy at each hospital stay and keep the document at home for easy retrieval by family and loved ones.
Every hospital’s medical records department is responsible to maintain and update patient records. It is wise of the nurse to make sure an advance directive has been filed and if not, to offer the service to the patient and family. Many people do not think about end of life decisions for many reasons, including fear, misinformation, ignorance, or even superstition about talking about death.
The nurse can simply confirm a document is included in the medical record and if not, invite the patient and family to do so. It is not the responsibility of the nurse to give legal advice, but they can refer patients and family members to medical records, who may offer guidance. Each state may have their own laws regarding filing a living will and a client can do a simple internet search to find the correct documents for their state. The hospital may have a template for a basic DNR.
In the past a DNR was “all or nothing” yet today, the DNR order may include a menu of choices including to withhold or give fluids, pain medications, nutrition, and other palliative measures. Many states also have the POLST document which stands for Physician Orders for Life Sustaining Treatment which are portable medical orders for seriously ill or fragile persons. It outlines the details of medical services desired and helps seriously ill people have more control over their health preferences.
Advance directives are medical preferences written by the person whereas a POLST is a medical order written by a physician that addresses critical medical decisions for a limited population with chronic and often fatal medical conditions. Patients can request that a physician complete a POLST and include it in their advance directives.
A DNR is a tool to help people have more control over life and death circumstances before a fatal injury or illness happens. In the heated topic of the right to choose about our own body, the DNR continues to be a valuable document to make those decisions known. Just by reading this article, hopefully it makes you think about your own choices and decisions should you be in a life threatening situation.
What do you want for the quality of your life or end of life? Do you have a DNR written, or have your advance directives securely stored in a retrievable location for family and medical personnel to find? Does your hospital or physician have a copy? If not, put that on your task list for this week and get it done. Your life may depend on it.
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