Do not resuscitate, or no code, is a legal order written either in the hospital or on
a legal form to withhold cardiopulmonary resuscitation or advanced cardiac life support, in respect
of the wishes of a patient in case their heart were to stop or they were to stop breathing.
"No code" is a reference to the use of "code" as jargon for "calling in a Code Blue" to
alert a hospital's resuscitation team.
The DNR request is usually made by the patient or health care power of attorney and allows
the medical teams taking care of them to respect their wishes.
In the health care community, allow natural death, is a term that is quickly gaining favor
as it focuses on what is being done, not what is being avoided.
Some criticize the term "do not resuscitate" because it sounds as if something important
is being withheld, while research shows that only about 5% of patients who require CPR
outside the hospital and only 15% of patients who require CPR while in the hospital survive.
Patients who are elderly, are living in nursing homes, have multiple medical problems, or
who have advanced cancer are much less likely to survive.
A DNR does not affect any treatment other than that which would require intubation or
CPR.
Patients who are DNR can continue to get chemotherapy, antibiotics, dialysis, or any other appropriate
treatments.
Alternative names Alternative namings and abbreviations for
this order are used depending on the geographic region.
DNR is a common abbreviation in the United States, Canada and the United Kingdom.
It may be clarified in some regions with the addition of DNI, although in some hospitals
DNR alone will imply no intubation.
Clinically, the vast majority of people requiring resuscitation will require intubation, making
a DNI alone problematic.
Some areas of the United States and the United Kingdom include the letter A, as in DNAR,
to clarify "Do Not Attempt Resuscitation."
This alteration is so that it is not presumed by the patient/family that an attempt at resuscitation
will be successful.
Since the term DNR implies the omission of action, and therefore "giving up", some have
advocated for these orders to be retermed Allow Natural Death.
New Zealand and Australia use the term NFR or Not For Resuscitation.
Typically, these abbreviations are written without periods between the letters, i.e.
AND/DNR not A.N.D./D.N.R..
Another synonymous term is "not to be resuscitated".
Until recently in the UK it was common to write "Not for 222" or conversationally, "Not
for twos."
This was implicitly a hospital DNR order, where 222 is the hospital telephone number
for the emergency resuscitation or crash team.
DNR compared with advance directive and living will
Advance directives and living wills are documents written by individuals themselves, so as to
state their wishes for care, if they are no longer able to speak for themselves.
In contrast, it is a physician or hospital staff member who writes a DNR "physician's
order," based upon the wishes previously expressed by the individual in his or her advance directive
or living will.
Similarly, at a time when the individual is unable to express his wishes, but has previously
used an advance directive to appoint an agent, then a physician can write such a DNR "physician's
order" at the request of that individual's agent.
These various situations are clearly enumerated in the "sample" DNR order presented on this
page.
It should be stressed that, in the United States, an advance directive or living will
is not sufficient to ensure a patient is treated under the DNR protocol, even if it is his
wish, as neither an advance directive nor a living will is a legally binding document.
Usage by country DNR documents are widespread in some countries
and unavailable in others.
In countries where a DNR is unavailable the decision to end resuscitation is made solely
by physicians.
Middle East DNRs are not recognized by Jordan.
Physicians attempt to resuscitate all patients regardless of individual or familial wishes.
In Israel, it is possible to sign a DNR form as long as the patient is dying and aware
of their actions.
United Kingdom
England and Wales In England and Wales, CPR is presumed in the
event of a cardiac arrest unless a do not resuscitate order is in place.
If they have capacity as defined under the Mental Capacity Act 2005 the patient may decline
resuscitation, however any discussion is not in reference to consent to resuscitation and
instead should be an explanation.
Patients may also specify their wishes and/or devolve their decision-making to a proxy using
an advance directive, which are commonly referred to as 'Living Wills'.
Patients and relatives cannot demand treatment which the doctor believes is futile and in
this situation, it is their doctor's duty to act in their 'best interest', whether that
means continuing or discontinuing treatment, using their clinical judgment.
If they lack capacity relatives will often be asked for their opinion out of respect.
Scotland In Scotland, the terminology used is "Do Not
Attempt Cardiopulmonary Resuscitation" or "DNACPR".
There is a single policy used across all of NHS Scotland.
The legal standing is similar to that in England and Wales, in that CPR is viewed as a treatment
and, although there is a general presumption that CPR will be performed in the case of
cardiac arrest, this is not the case if it is viewed by the treating clinician to be
futile.
Patients and families cannot demand CPR to be performed if it is felt to be futile and
a DNACPR can be issued despite disagreement, although it is good practice to involve all
parties in the discussion.
United States In the United States the documentation is
especially complicated in that each state accepts different forms, and advance directives
and living wills are not accepted by EMS as legally valid forms.
If a patient has a living will that states the patient wishes to be DNR but does not
have an appropriately filled out state sponsored form that is co-signed by a physician, EMS
will attempt resuscitation.
The DNR decision by patients was first litigated in 1976 in In re Quinlan.
The New Jersey Supreme Court upheld the right of Karen Ann Quinlan's parents to order her
removal from artificial ventilation.
In 1991 Congress passed into law the Patient Self-Determination Act that mandated hospitals
honor an individual's decision in their healthcare.
Forty-nine states currently permit the next of kin to make medical decisions of incapacitated
relatives, the exception being Missouri.
Missouri has a Living Will Statute that requires two witnesses to any signed advanced directive
that results in a DNR/DNI code status in the hospital.
In the U.S., cardiopulmonary resuscitation and advanced cardiac life support will not
be performed if a valid written "DNR" order is present.
Many US states do not recognize living wills or health care proxies in the prehospital
setting and prehospital personnel in those areas may be required to initiate resuscitation
measures unless a specific state sponsored form is appropriately filled out and cosigned
by a physician.
Canada Do not resuscitate orders are similar to those
used in the United States.
In 1995, the Canadian Medical Association, Canadian Hospital Association, Canadian Nursing
Association, and Catholic Health Association of Canada worked with Canadian Bar Association
clarify and create a Joint Statement on Resuscitative Interventions guideline for use to determine
when and how DNR orders are assigned.
DNR orders must be discussed by doctors with the patient or patient agents or patient's
significant others.
Unilateral DNR by medical professionals can only be used if the patient is in a vegetative
state.
See also Advance Health Care Directive
Cardiac arrest Power of attorney
Letting die Euthanasia
Uniform Rights of the Terminally Ill Act Patient Self-Determination Act
Slow code References
External links Do Not Resuscitate Orders Published by the
U.S. National Library of Medicine Decisions Relating to Cardiopulmonary Resuscitation
Published by the Resuscitation Council