Has your primary care physician, at your request, written an order that you wish to wear your "DNR: Comfort Care" or "DNR Comfort Care Arrest" bracelet both during and after your care at Cleveland Clinic?

If so, this bracelet, in addition to your doctor's order in the chart and the Advanced Directives which you have signed inform all of your physicians and nurses how you have chosen to be cared for during the latter stages of your illness.

We want you to know that your doctors and nurses respect your wishes and want to make you comfortable while providing you the best care.

What are DNR Comfort Care directives?

DNR (Do Not Resuscitate) Comfort Care directives tell all healthcare workers that they must not do the following:

Start an Intravenous Line (IV)

An intravenous line (IV) is standard practice before any operation can be started. Intravenous lines are used to administer medication, like pentothal, to permit a pleasant induction to anesthesia. Many other medications are given during an anesthetic, including pain medicines and special medicines to prevent nausea and vomiting. An IV is essential to prevent dehydration in patients who have had to fast for eight or more hours before their operation. The IV is used for many purposes while the patient is under anesthesia and is discontinued after a patient has regained consciousness, is comfortable, and is able to take fluids by mouth. An IV is considered essential to the success of the anesthesia and surgery, and attempting surgery without one is, in most situations, impossible.

Provide Respiratory Assistance

Many patients do not realize that many anesthesia medications slow down or completely stop a patient's ability to breathe for himself. Anesthesiologists are trained to "breathe for the patient" with a breathing bag and mask and by inserting special breathing tubes during the time when anesthesia medications are being given. Once the patient wakes up after surgery, breathing for the patient is no longer necessary, and the breathing tubes and special airways are removed.

It is important that our patients understand that anesthesia is quickly reversible, and that most breathing tubes are removed before a patient is awake enough to remember having one. While anesthesia medications gases are being given to the patient, special breathing equipment is essential for the safety and success of the anesthesia and surgery.

Insert a Breathing Tube or Artificial Airway

Patients have told us that one of their greatest fears is to be separated from their families in the last few weeks to months of their lives. Patients with advance directives have expressed concern that they might have a breathing tube preventing them from being able to talk to their loved ones. The breathing tube, especially if a ventilator is needed to keep a patient breathing, would force our patients to spend precious days in the hospital and away from the people they love.

We want our patients to know that your physicians and nurses would not chose to spend the end of our own lives this way. Our wishes and plans for you are the same plans we would want for our own families and for ourselves in the same situation.

When a patient becomes unconscious because of anesthesia, he or she is not only unable to breathe for themselves, but they cannot cough or protect their lungs from stomach acids which can regurgitate to the back of their throats during surgery. The breathing tube prevents this acid from getting into the lungs and making a patient sicker. It also permits excellent oxygenation of the patient when he/she is under the influence of anesthesia drugs. It is an anesthesiologist's duty to protect our patients when they cannot protect themselves while unconscious from anesthesia. In most circumstances, your anesthesiologist will remove the breathing tube as soon as you are awake.

Breathing tubes are not always necessary, but when they are needed to protect the patient from breathing in stomach contents or from a swollen airway, they are used only after a patient is asleep and removed as a patient is waking up. Only in rare cases are breathing tubes kept in for another hour or two while the patient is in the recovery room. Most patients are unaware that a breathing tube was ever used. Your doctors have no plans for a breathing tube to remain after an anesthetic, except in the rare case that it might be needed for a few more hours after surgery.

For your anesthesiologist's purposes, any breathing tube is temporary and only in certain types of surgery is it considered essential to the success of the anesthesia and surgery.

Initiate Cardiac Monitoring

In the same way that a pilot uses monitors on an airplane to make decisions about wind velocity and direction, altitude and changes in the weather, anesthetists use monitors to make certain that a patient is breathing well and is not "too deep" or too lightly anesthetized. Also, monitors help anesthetists to know how anesthesia medicines and the surgery itself have affected blood pressure or heart rhythm. Monitors help your anesthetist prevent heart attacks, strokes, and inadequate oxygen levels. Monitors even help to prevent awareness under anesthesia! Monitors are all removed once a patient is recovered from anesthesia medicines. Use of monitors are temporary and considered essential to the safety and success of the anesthesia and surgery.

Perform Other Specific Interventionsยป

DNR Comfort Care directives tell all healthcare workers that they also must not administer resuscitative drugs, administer chest compressions, defibrillate or cardiovert.

Many patients ask how the DNR: Comfort Care status will affect the decisions of physicians during any operative procedures. You and your loved ones might want to give some thought to the following options should surgery be needed:

Option 1: Discontinue Advance Directives During Surgery

I would like all Advance Directives to be discontinued during anesthesia and surgery and fully reinstated once I am discharged from the recovery room. If I were to have a cardiopulmonary arrest during surgery, I would want my doctors to use their clinical judgment if they were reasonably sure that CPR would be quickly successful and that, in their judgment, I would be unlikely to have permanent disability from their efforts. If in their judgment they felt that CPR would not have a successful outcome, I would ask that all CPR be withheld.

Option 2: Continue Advance Directives But Modify During Surgery

I would like to have my Advance Directives continued but modified during surgery and my immediate recovery. I refuse CPR, but I will permit those measures: medication, airway issues and monitoring, which are considered essential for a safe and successful outcome from anesthesia and surgery. I would ask that my DNR: Comfort Care Advance Directives be fully reinstated upon my discharge from the recovery room.

Essentially, I am consenting to the following:

  1. monitoring of ECG, blood pressure, oxygenation, exhaled gases and vapors and any intraoperative monitors which are considered essential for a good outcome;
  2. temporary manipulation of my airway and breathing with breathing tubes and ventilators, when needed; and with orders that I will be breathing on my own without these devises before discharge from the recovery room;
  3. use of special drugs to increase my blood pressure or correct an abnormal heart beat if these were caused by anesthesia medicines or surgical manipulation, can be immediately corrected, and are not given in the doses used during cardiopulmonary resuscitation.

I refuse to permit:

  1. chest compressions;
  2. defibrillation of my heart;
  3. use of techniques or large doses of resuscitative drugs which would be considered CPR.

Option 3: Request No Changes Made to DNR: Comfort Care Orders

I request no changes be made in my DNR: Comfort Care orders. If surgery is absolutely necessary, I permit use of the following:

____an IV
____anesthesia medicine
____breathing equipment
____fluids
____pain medicine
____medicine to stop nausea
____monitors
____breathing tube
____ventilator
____blood
____blood components
____heart/blood pressure medicine

Download Do Not Resuscitate Orders and Comfort Care brochure.