Should you have a "DNR"?
As I was leaving a new client's home after arranging for the start of home care services, her daughter mentioned to me at the door that her mother had a "DNR" in place and was I OK with that? I immediately said: "Yes, no problem. We are familiar with DNR's". But as I drove away, I began to wonder if in fact I really new as much about DNR's as I should. So I asked an expert for a detailed explanation. I contacted Harriet Holzman Onello (781-862-4507) an elder law attorney in Lexington. Ms Onello's explanation follows.
A DNR order deals specifically and exclusively with CPR treatment. It is very important to understand that by refusing CPR with a DNR, the patient is not refusing other kinds of treatment, such as pain control, oxygen, surgery for other medical causes, splinting or immobilizing any body parts, or general care and comfort. The DNR order is restricted to situations in which the patient has suffered cardiac or respiratory arrest. Without written DNR instructions, hospital staff and emergency medical technicians will take all necessary steps to resuscitate a person who has suffered cardiac or respiratory arrest. This is called "full code" status. The procedures by which a "near death" person may be resuscitated include: chest compressions, inserting a breathing tube into the trachea, administering resuscitative drugs and/or IV, and defibrillation by electric "shock". The shorthand for these procedures is CPR, for cardiopulmonary resuscitation.
For in-hospital patients, the choice to refuse CPR is generally made as a result of consultation between patient and doctor, or between the patient's legal representative or family and the doctor. While hospitals have protocols for accommodating a DNR, how to treat seriously ill patients who are not in-hospital when they suffer cardiac or breathing arrest is not so clear. In 1997 Massachusetts established a legal protocol for EMT's to honor a validly executed DNR order for patients who are not in a hospital. This is an out-of -hospital order that is written on a state prescribed form, available through one's physician. This is called the "Comfort Care/Do Not Resuscitate Order". Both the patient and the patient's physician must sign the order. The form indicates an effective date and an expiration date, if the patient wishes the order to last for a limited time. An expiration date does not have to be specified.
A valid DNR order (both for in-hospital and out-of-hospital patients) should be signed by a competent individual over the age of 18, or by a duly designated legal representative of an incompetent individual, such as a court-appointed guardian or a designated Health Care Agent. The physician who signs a DNR may also rely on the signature of an immediate family member who seems able to communicate the wishes of the patient. The out-of-hospital DNR may be revoked at any time. If an emergency medical provider has any doubt about the validity of a DNR, or if the patient or a family member raises questions, then the EMT must provide full resuscitation. The regulations governing Comfort Care/DNR orders do not permit partial resuscitation or selective administration of CPR procedures. Once a person who has executed the Comfort Care/DNR order is hospitalized, then his treatment will be governed by the hospital policies on DNR, though the hospital staff is likely to take the executed Comfort Care/DNR statement into consideration in making a treatment plan for the hospitalization.
As a practical matter, EMT personnel do not generally ask if the patient has executed a Comfort Care/DNR order when they respond to an emergency call. Their mission is first and foremost to deal with the medical emergency at hand. For this reason, it is advisable to have the state-approved Comfort Care/DNR document available to show the EMT, with a copy that can be taken with the patient. Massachusetts emergency personnel will refrain from administering CPR only upon seeing the approved state form. Verbal instructions or showing a valid Health Care Proxy are not effective for emergency workers, who will commence CPR without proper documentation to the contrary.
Persons who suffer from serious chronic illness, whether living at home, in an assisted living residence, or in a nursing home, may want to consider the option of executing a Comfort Care /DNR order. Any number of difficult questions enter into this process, and should be discussed at length with the treating physician and perhaps also with family members. The underlying consideration to discuss with the physician is whether the patient would be restored to his prior health, or better, with CPR; or is the patient's prognosis for quality of life so poor that CPR would only prolong dying rather than restore health. What should be made clear in any case is: 1) a DNR order applies only to CPR treatment and does not preclude other medical treatment; and 2) a DNR order can be reversed at any time that the patient or the patient's agent requests.
Jack Cross is President of Home Instead Senior Care a provider of companionship and home care for the elderly. He can be reached at 781-402-0060
If you suspect abuse or are experiencing it yourself, seek help before it's too late. Anyone can report suspected abuse, even a casual observer. If you are a caregiver and are feeling ready to crack, ask for help too.
Jack Cross is President of Home Instead Senior Care-Lexington a provider of companionship and home care for the elderly. He can be reached at 781-402-0060 or jack.cross@homeinstead.com.