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Do Not Resuscitate Orders & Comfort Care

What does a "do not resuscitate" order mean?

A "do not resuscitate" (DNR) order indicates that a person — usually with a terminal illness or other serious medical condition — has decided not to have cardiopulmonary resuscitation (CPR) attempted in the event his or her heart or breathing stops. In most situations, a DNR order is written by a physician after discussing the burdens and benefits of CPR with the patient or the patient’s surrogate decision maker.

If CPR saves lives, why would anyone want a DNR order?

Various methods of CPR often involve more than chest compressions and mouth-to-mouth resuscitation. CPR also might include the use of powerful drugs or electric shock to start the heart beating again, or might require the insertion of a breathing tube. Although CPR can save lives, it frequently does not work. Even if a person is resuscitated, he or she might suffer painful injuries during CPR or might be left in a worse condition than before. Also, people with terminal illnesses or other serious medical conditions might not want to have CPR performed on them, even if that means they might die as a result.

You and your physician should discuss the burdens and benefits of CPR, and the options that are best for you in your medical condition.

In some situations, CPR will not be life-saving, and will only cause harm. If the physicians caring for you or your loved one believe strongly that this is the case, they will discuss with you why it is not being offered as an option.

How do I make my wishes known about CPR?

If you do not wish to receive CPR during a medical emergency, you must discuss your wishes with a physician who can inform you about the details of a DNR order. You have the right to refuse CPR, but you might not be able to state your wishes during a medical emergency.

What does Ohio law say about DNR orders?

Ohio law recognizes two standard categories of DNR orders: 1) DNR Comfort Care, and DNR Comfort Care—Arrest. Both orders aim to protect a person’s right to choose not to receive CPR. See below for the differences between the two DNR orders.

State-approved DNR Comfort Care orders are designed to prevent health care professionals and emergency workers from performing CPR, whether you are inside or outside a health care facility. However, health care providers will be required to provide you with comfort care, even if CPR is withheld. Comfort care is any action taken to promote patient comfort, such as administering pain medication or offering emotional support. State-approved DNR Comfort Care orders cannot be cancelled by a family member without your consent, and are considered "portable" because they remain in effect as you travel to and from a hospital or other health care facility.

What are my options for DNR orders?

There are three different kinds of DNR orders available at Cleveland Clinic hospitals. The first two options are based on the state-approved DNR Comfort Care orders:

1) DNR Comfort Care

DNR Comfort Care orders (DNRCC) require that only comfort care be administered before, during, or after the time a person’s heart or breathing stops. This type of order is generally regarded as proper for a patient with a terminal illness, short life expectancy, or with little chance of surviving CPR.

2) DNR Comfort Care-Arrest

DNR Comfort Care-Arrest orders (DNRCC-Arrest) permit the use of life-saving measures (such as powerful heart or blood pressure medications) before a person’s heart or breathing stops. However, only comfort care may be provided after a person’s heart or breathing stops.

3) DNR Specified

Valid only at Cleveland Clinic hospitals, DNR Specified orders are uniquely tailored by your physician. They may permit the use of some CPR treatment methods (such as powerful medications) while possibly prohibiting other methods (such as electric shock).

All three options are available to you if you are hospitalized in a Cleveland Clinic hospital. The first two types of DNR orders can be changed to outpatient DNR orders when you leave the hospital. If you are an outpatient, the first two types of DNR orders can be written for you, but not the third type.

If you are considering having a DNR order written, you should discuss these options with your physician to determine which DNR order might be best for you, given your medical condition.

How will health care professionals know what DNR order I have?

While in the hospital, you will be asked to wear a purple DNR wrist bracelet that will alert your health care professionals that a DNR order has been written for you by your physician.

For your safety and to avoid confusion while in the hospital, you will be asked to remove any colored wristbands worn in support of social causes.

If you are able to leave the hospital and you want a DNRCC or a DNRCC-Arrest order to remain as part of your treatment plan, your physician can provide you with a state-approved DNR form, a DNR bracelet, or a DNR wallet card. If you receive care at home, you should tell your family and caregivers where to find your DNR order form and identification.

What happens if I have a DNR order and I need surgery?

In the event that you need surgery, you and your physician will re-evaluate your DNR order prior to the procedure. Together, you and your physician will decide which treatment methods should be used during surgery and immediately afterward.

What happens to my DNR order once I leave the hospital?

State-approved DNR orders (DNRCC and DNRCC-Arrest) remain in effect if you are discharged from the hospital, and should be honored by emergency squads and other health care professionals throughout Ohio. Before leaving the hospital, you should talk to your physician about providing you with state-approved means of DNR identification, such as a DNR form, a DNR bracelet, or a DNR wallet card.

DNR Specified orders apply only within Cleveland Clinic hospital. If you have a DNR Specified order and are leaving the hospital, the order ends when you are discharged from the hospital. You and your physician should discuss the option of changing the order to a DNR Comfort Care or DNR Comfort Care-Arrest order.

What if I change my mind after a DNR order is written?

You always have the right to change your mind and request that CPR be administered during a medical emergency. If you do change your mind, you should destroy all DNR forms and identification that you were given or you are wearing. You also should inform your physician and your nurse immediately so that consideration can be given to revoking your DNR order. You also should inform your family and other caregivers of the change in your decision.

What if I’m healthy now but do not want CPR if I become terminally ill?

You can appoint a Health Care Power of Attorney (HCPoA) and discuss your wishes in advance with that person. Information on Ohio advance directives and forms can be found at: http://olrs.ohio.gov/.

You can also state in a Living Will that you do not want CPR. However, a Living Will does not apply in Ohio until you become terminally ill or permanently unconscious and can no longer make your own health care decisions. In Ohio, your Living Will takes effect once two physicians determine that your condition meets either of these criteria. Your physician will then write one of the DNR Comfort Care orders according to your specified wishes.

For more information:

To request ethics assistance or a formal ethics consultation, contact the Department of Bioethics at 216.444.8720 or 1.800.223.2273, ext. 48720, 8:00 a.m. to 5:00 p.m., Monday through Friday.

After regular business hours, call 216.444.2200 and ask that Bioethics be paged at pager # 22512.

References

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Can't find the health information you’re looking for?

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 8/19/2013...#8866