According to a Nursing 2006 article entitled “Man vs. Machine: Who’s Better at CPR,” survival rates after CPR in two studies range from 2.9% to 29.5%. Although modern medical advances may enable the healthcare team to sustain signs of life longer than in the past, not everyone wants invasive care or to have CPR performed in the event of cardiopulmonary arrest. Do those who choose no CPR in turn receive inadequate care?
In the Past
Years ago, staff members would not rush to certain patients' rooms to perform life sustaining measures or would avoid other serious attempts at aggressive resuscitation. This might have been done with or without the knowledge or consent of the patient and/or his representative. Examples of terms used for these unethical responses include:
- Slow code
- Show code
- Light blue code
- Hollywood code
Better Options Today
Today, people can clearly define advance directives through a:
- Living Will
- Health Care Power of Attorney (HCPOA)
- Out-of-Hospital DNR order (may be written by a competent adult in some states or a physician; click here to see an example)
- In-hospital DNR order (typically written by the physician)
In some instances, wishes expressed in a Living Will or HCPOA can only be carried out legally if a DNR order is written. Patients are typically classified as either full code, in which all appropriate lifesaving measures will be attempted, or DNR, in which certain types of care will be withheld or withdrawn.
Information Included on DNR Orders
A DNR Order may indicate whether or not Cardiopulmonary Resuscitation (CPR) should be performed in the event of respiratory or cardiac arrest. A DNR order may also indicate varying levels of care when not in cardiopulmonary arrest and may provide choices such as:
- A Full Scope, in which advanced airway/ventilation, cardioversion, and other invasive medical treatments can be provided in addition to less invasive treatments.
- A Limited Scope, in which only less invasive treatment, such as cardiac monitoring and intravenous fluids will be provided.
- Comfort Measures, in which the focus of care shifts to the purpose of relieving pain and suffering while providing for basic hygiene, positioning, medication and oxygen administration and suction and manual treatment of airway obstruction as needed. (For example, if you start to choke while eating dinner, the staff should administer abdominal thrusts or the Heimlich maneuver as needed. The collection of data such as vital signs might be discontinued if the collection of such data becomes unnecessary or causes increased pain for the patient.)
Additional information specified on many DNR-related documents may include specific parameters for interventions such as:
- Transfer to a different level of care
- Antibiotics
- Length of intravenous (IV) fluid administration
- Feeding tubes
- Other instructions that can be added as desired
Identification of DNR Status
Many hospitals utilize an identifying bracelet so that other staff members will be alerted to code status. Some states also allow for the use of other bracelets or necklaces, such as MedicAlert, and may also allow online storage of DNR status information.
“No Code” versus “No Care”
Some people mistakenly assume that if they become a “no code” or DNR status that all care will be terminated. A person who is DNR status should be treated like any other patient with adjustments in care only as specified on the order. These care expectations are clearly listed, and the patient and/or patient representative(s) are typically involved in the decision-making process.
Revoking or Changing DNR Status
A DNR order may be revoked or changed by the patient or appropriate representative at any time.
Some DNR orders may be temporarily suspended if, for example, a patient is going to have surgery.
A DNR Order provides the patient and/or her representative(s) the opportunity for clear communication regarding wishes for end of life treatment. While some people wish to utilize every life sustaining treatment, others may choose to withdraw or withhold certain treatments through the use of a DNR order. Because a DNR order cannot specify every possible medical need that may arise, some people also opt to designate a HCPOA.
