Cardiopulmonary Arrest, Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR)
Cardiopulmonary arrest means that your heart and breathing have stopped. When this happens, it is sometimes possible to restart your heart and breathing with an emergency treatment called cardiopulmonary resuscitation (CPR).
What interventions may be included in CPR?
Chest compressions are always the first intervention. They intend to pump blood out of the heart and to the main organs during CPR, until the heart starts pumping automatically again.
When you become unconscious because of cardiac or respiratory arrest, you are not able to breathe, cough or protect your lungs from aspiration. In order to increase the success of CPR, there needs to be high oxygen levels in your blood.
Respiratory assistance entails placing a breathing tube and connecting with a manual device or a breathing machine. Usually it takes time for you to breathe independently from the breathing machine. The breathing tube not only permits oxygen to flow, but also prevents aspiration of gastric content into the lungs.
Cardiac arrest sometimes presents arrhythmias that are treated with defibrillation or cardioversion, an electric shock delivered on the chest.
During cardiac arrest, resuscitative drugs are administered to re-start the heart and fix imbalances. An intravenous (IV) line is placed and used to administer medication during a cardiac or respiratory arrest. Cardiac Monitoring is initiated. In the same way that a pilot uses monitors on an airplane to make decisions about wind velocity and direction, doctors use monitors to determine which treatment are needed during CPR. Monitors will display oxygen levels in blood, heart rhythm, blood pressure, etc. Sometimes doctors have to do other invasive interventions, like aspirating air from your lung, or fluid from around your heart.
The information above describes what happens during cardiopulmonary resuscitation. The following sections describe information about do not resuscitate orders so that you may make informed decisions about your wishes.
Do Not Resuscitate (DNR) Orders
State of Ohio
A Do Not Resuscitate (DNR) order means that CPR is not to be conducted in case of cardiac or respiratory arrest. In the state of Ohio there are two DNR orders: DNR-CCA (Comfort Care Arrest) and DNR-CC (Comfort Care). Only a physician or Licensed Independent Practitioner can write a DNR order.
- DNR-CCA orders permit the use of life-saving treatments before your heart or breathing stops. However, only comfort care is provided after your heart or breathing stops.
- DNR–CC orders require that only comfort measures be administered before, during, or after the time your heart or breathing stops (as soon as the order is written). This type of order is generally regarded as proper for you if you have a terminal illness, short life expectancy, or little chance of surviving CPR. All treatments are directed towards keeping you comfortable and with the best quality of life possible.
State of Florida
In the state of Florida, there is only one DNR order. This order means that CPR will not be conducted in case of cardiac or respiratory arrest. If you want to forgo treatments before the heart or breathing stops, the doctor or a Licensed Independent Practitioner will write your specific wishes in the electronic medical record.
DNR Comfort Care Protocol
What is the DNR Comfort Care protocol?
DNR-CC protocol tell all healthcare workers what they must do and not do. For example, healthcare providers WILL NOT:
- Administer chest compressions
- Insert artificial airway
- Administer resuscitative drugs
- Defibrillate or cardiovert
- Provide respiratory assistance
- Initiate resuscitative IV or initiate cardiac monitoring
The healthcare providers WILL:
- Suction the airway
- Administer oxygen
- Position for comfort
- Splint or immobilize
- Control bleeding
- Provide pain medications
- Provide emotional support
- Contact other appropriate healthcare providers such hospice, home health, etc.
How do I make my wishes to not receive CPR known?
If you do not wish to receive CPR during a medical emergency, you must discuss your wishes with your surrogate decision maker and with your physician. Your physician will inform you about the different types of DNR orders and which one would be best for your case. Once a physician has written a DNR order for you, you may use one of the following options so others know what your wishes are: the State of Ohio Portable DNR Form, a wallet ID card, or DNR jewelry such as necklaces or bracelets, which can be found on the Ohio Department of Health website.
How do healthcare providers know if I have a DNR order?
If you are admitted to the hospital, the order will be entered into your electronic medical record and a hospital DNR wristband will be applied.
Once discharged, it is recommended that you keep the State of Ohio Portable DNR form prominently displayed in your home, and utilize DNR jewelry, and share your wishes with your loved ones. You are not required to carry the ID card or to wear an identification item. However, if a provider cannot find a DNR identification, all efforts to resuscitate you and to sustain life will be applied as this is an appropriate legal response in the absence of DNR identification.
Under the law, emergency medical services (EMS) workers are not required to search patients for DNR identification. However, if DNR identification is discovered, the EMS personnel will honor the DNR order.
What happens if I have a DNR order and am scheduled for surgery?
Many patients ask how the DNR order will affect the decisions of physicians during any operative procedures. The anesthesia may affect the breathing and even the heart function. You and your loved ones might want to give some thought to the following options should surgery be needed:
Option 1: Discontinue DNR order During Surgery
I would like the DNR order 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 do CPR.
Option 2: Keep the DNR order during surgery
I would like to keep the DNR order and the doctors not to provide CPR should my heart stops. Your doctors will ask you if you agree for them to use their clinical judgment. I may agree 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.
Things to consider regarding CPR
CPR is most often used in emergency situations, for example if you have a serious injury or suffer a heart attack. However, CPR is not always automatically used; this depends on the circumstances and the doctor’s estimate of how likely it is to be effective. If you are already very seriously ill and nearing the end of life, there may be no benefit in trying to revive you. In this case, CPR may not be attempted because it may hurt your body without any benefit. CPR will not be used if you have a DNR order because you agreed in advance that you do not wish to receive it. Discussions about whether to use CPR are important. It is important to understanding the circumstances and the doctor’s estimate of how likely it is to be effective.
The chances of CPR restarting your heart and breathing will depend on:
- Why your heart and breathing have stopped
- Any illnesses or medical problems
- Your overall health condition
When CPR is attempted in a hospital it is successful in restarting the heart and breathing in less than 2 out of 4 patients. However only about 1 out of 4 patients survive long enough to leave hospital. The chances of survival are much lower for patients with serious underlying conditions and for those not in hospital.
The techniques used to restart your heart and breathing sometimes cause side effects, for example, bruising, fractured ribs and punctured lungs. People who are revived are often still very unwell and need more treatment, usually in an intensive care unit. Some patients make a full recovery; some recover but have health problems. Some people never get back the level of physical or mental health they previously enjoyed. Some have brain damage or go into a coma. People with many medical problems are less likely to make a full recovery.
End of Life Support
Let us know what you hope for at the end of life so we can support you
Most patients have said they want to be pain free and surrounded by loved ones. 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 have expressed concern that they might have a breathing tube preventing them from being able to talk to their loved ones. Doctors offer breathing machine to keep patients alive to give time to treat the underlying disease. If it is not possible to cure the underlying disease, the breathing tube would force our patients to spend precious days in the hospital and away from the people they love at the end of life.
We believe that understanding the information provided here and having discussions with your loved ones and doctors will help you have your wishes known and respected at the end of life. Your doctors want to understand your wishes so that they can align your treatments to your wishes. Your doctors will respect your preferences at the end of life.
This information 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.
Our Team is Here to Help
As part of your healthcare team, nurses, social workers, chaplains and members of the Bioethics Department are available to you for support and guidance. We encourage you to take advantage of their assistance. Learn more about them:
Nurses can assist you by answering questions or directing you to other members of the healthcare team. Furthermore, they can assist you in discussing treatment decisions with your doctor. They can also help you consider your choices or options and deal with your feelings and concerns.
Our chaplains can offer assistance with spiritual or personal problems and needs. They also can assist you or your family during times of crisis. If you face decisions about life support systems, the chaplains can offer you guidance. They will help you consider your options and help you deal with your feelings and beliefs.
Social workers also are available to you and your family. They can guide you through the difficult social and emotional questions that can arise during times of illness. Social workers can help with family stresses and coping with the results of a decision. Their counsel and information can provide you and your family with additional support to face these decisions together.
Ethics consultation is a free service provided to all patients and their families through the Bioethics Department. Upon request, the Ethics Consultation Service can provide ethical advice related to issues arising in the course of patient care.
Ask your physician, nurse or other member of the healthcare team to communicate your request for an ethics consultation. You may also choose to call the Bioethics Department directly at 216.444.8720 during normal business hours. On evenings and weekends, you can ask the hospital operator (216.444.2200) to page the Ethics Consultation Service.