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    Questions and Answers: Cardiopulmonary Resuscitation, Do-Not-Resuscitate Orders and End-of-Life Decisions

    • What is cardiopulmonary resuscitation?
    • Answer:

      Cardiopulmonary resuscitation (CPR) refers to a group of procedures that may include artificial respiration and intubation to support or restore breathing, and chest compressions or the use of electrical stimulation or medication to support or restore heart function.

      Intubation refers to "endotrachael intubation" which is the insertion of a tube through the mouth or nose into the trachea (windpipe) to create and maintain an open airway to assist breathing. These procedures can either replace the normal work of the heart and lungs or stimulate the person's own heart and lungs to begin working again.

    • When is CPR used?
    • Answer:

      CPR is given when a person stops breathing (respiratory arrest) and the heart stops beating (cardiac arrest). During cardiac arrest all body functions stop, including breathing and the blood stops going to the brain. Sometimes, however, a patient may stop breathing while the heart continues to beat. This "respiratory arrest" may result from choking, or serious lung or neurological disease. If untreated, respiratory arrest will rapidly lead to cardiac arrest.

    • Why would someone want to refuse CPR?
    • Answer:

      The burdens of CPR can outweigh the benefits. CPR's success rate depends heavily upon how quickly it is started and the person's underlying medical condition. CPR was never intended for seriously ill or dying people. Originally, it was developed to treat people who have an unexpected arrest due to a heart attack, an adverse reaction to anesthesia, a drug overdose, or an accident like drowning or electrocution. Although healthy adults who suffer from an unexpected arrest have the greatest chance of being successfully resuscitated, CPR does not always work.

      Research has found that the overall rate of long-term survival after CPR is only 15% or less, and depends heavily on whether someone was present at the time the arrest occurred in the hospital or out of the hospital; the cause of the arrest and the health of the person having the arrest. The success rate is extremely low for people who are seriously ill or dying. One study shows that people with overwhelming infection have a less than 3% chance of being discharged from a hospital after CPR; those with advanced cancer that has spread to other parts of the body have almost no chance.

      When a person is seriously ill or dying, cardiac arrest marks the terminal moment of a disease when the body is shutting down. For a dying person, cardiac arrest can bring a natural end to the exhaustion of battling a disease. If CPR is initiated, it disrupts the body's natural process and prolongs the dying process. Although CPR may restart the heart, its success may be temporary or it may leave the person with additional problems such as broken bones, brain damage or dependent on a ventilator. Many dying persons and their families wish to avoid CPR because it is an aggressive and invasive procedure.

    • What is Do-Not-Resuscitate (DNR) order?
    • Answer:

      A DNR order is a physician's written order instructing healthcare providers not to attempt CPR in case of cardiac or respiratory arrest. A person with a valid DNR order will not be given CPR. Unlike a living will or a medical power of attorney, a patient cannot prepare a DNR order. Although it is written at the request of a patient, his or her family or healthcare agent, it must be signed by a physician to be valid.

    • Why is a DNR order needed to refuse CPR?
    • Answer:

      CPR is an emergency procedure that is potentially life saving if initiated immediately. Without a physician's order not to resuscitate, the healthcare team must initiate CPR because in an emergency there is no time to call the attending physician, determine the person's wishes or consult the family or healthcare agent. If a person wishes to refuse CPR, that wish must be communicated to the healthcare team by a DNR order signed by the attending physician.

    • Will instructions in a living will enable a person to avoid CPR?
    • Answer:

      In an emergency there is no time to consult a living will. Unless the healthcare team has received clear instructions from the attending physician not to resuscitate a person, they must initiate CPR.

      Instructions about CPR that are documented in a living will indicate a person's wish not to receive CPR in certain circumstances. This wish must be translated into a physician's DNR order; without a DNR order, the instructions will not be honored.

    • Does a DNR order mean a person won't receive any treatment?
    • Answer:

      No. "Do not resuscitate" does not mean, "do not treat." A DNR order covers only one type of medical treatment CPR. Other types of treatment, including intravenous fluids, artificial nutrition and hydration, and antibiotics, must be discussed with the physician separately. In addition, although CPR will not be given to a person who has a DNR order, all measures can and should be used to keep a person comfortable.

    • Are DNR orders governed by state law?
    • Answer:

      While states may have laws governing DNR orders for healthcare facilities, more often, DNR orders are regulated by a facility's policy. All healthcare facilities, including nursing homes and rehabilitation centers, are required to have a DNR policy in place if they wish to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a private, not-for-profit, voluntary accrediting agency.

      JCAHO requires that a DNR policy describe the following: how decisions about DNR orders are made, how conflicts in decision making are resolved, and the role of physicians, nursing personnel, other staff and family members in reaching a decision about a DNR order. The policy also must ensure that the rights of patients are respected. The policy should be in writing and available to patients and their families if requested.

    • Who can consent to a DNR order?
    • Answer:

      An individual, his or her healthcare agent, or a family member (as provided by state law), can agree to a DNR order. Although policies may differ, in general a DNR order must first be discussed with the patient if he or she has the capacity to make medical decisions. If the patient is incapacitated and is unable to make this decision, a physician can then consult instructions in a living will or speak with an appointed healthcare agent. If there is no written advance directive, a physician might consult a family member or a close friend of the patient.

      Sometimes, physicians are reluctant to start discussions about DNR orders. Patients and their families should take the initiative to approach the physician about a DNR order, if they think it might be appropriate, and not wait for the physician to raise the issue. When should a DNR order be discussed with a physician?

      If a person is seriously ill or dying, discuss a DNR order with the physician as soon as possible. Ideally, a decision about a DNR order should be made while a person is alert and able to think clearly, and not at the last moment when he or she may be weak and disoriented from the illness.

      However, if a person does not have the capacity to make a decision about a DNR order, it is important that this discussion be initiated as soon as possible. Ideally the physician would raise the issue, but the family or healthcare agent should not hesitate to approach the physician with their concerns. A discussion initiated sooner rather than later gives patients and their families time to reflect on the decision and, in the end, offers the best protection against unwanted treatment.

    • What questions should be asked when discussing a DNR order with a physician?
    • Answer:

      Before making a decision about CPR, patients and their loved ones need to understand both the burdens and benefits of CPR. These can vary depending on individual's underlying condition. The physician should be prepared to:

      • describe the procedures;

      • address the probability for successful resuscitation based upon the patient's medical condition;

      • define what is meant by "successful" resuscitation; Does "successful" mean the patient will be able to leave the hospital? In what condition? If it is unlikely that the person will be able to leave the hospital, what can the resuscitation attempt accomplish?

      If the physician does not think resuscitation would be successful, he or she should be willing to discuss the reasons why.

    • What is a Do-Not-Intubate (DNI) Order?
    • Answer:

      When a DNR order is discussed the doctor might ask if a "do-not-intubate" order also is wanted. Intubation may be considered separately from resuscitation because a person can have trouble breathing or might not be getting enough oxygen before the heart actually stops beating or breathing stops (a cardiac or respiratory arrest).

      If this condition continues a full arrest will occur. If the person is intubated, cardiac or respiratory arrest might be averted. During intubation a tube is inserted through the mouth or nose into the trachea (windpipe) in order to assist breathing; a machine (ventilator) may be connected to that tube to push oxygen into the lungs.

      Refusal of resuscitation is not necessarily the same as refusal of intubation. It is important that all concerned understand the decisions being made since some institutional DNR policies include intubation, while others treat it separately.

      If a person does not want life mechanically sustained it is important to be sure that intubation is addressed as part of the discussion of DNR. Comfort measures should be taken to prevent any discomfort.

      There may be circumstances under which accepting intubation while also having a DNR order is appropriate, but it is essential that the patient or the person speaking on behalf of the patient and the doctor have a thorough discussion so that the decision is clear.

    • What if an individual, health care agent, or family member disagrees with the physician's recommendation?
    • Answer:

      First, the patient or appropriate family member should approach the physician to clear up any misunderstandings about the patient's wishes, prognosis, and treatment options. They can also request that a meeting be arranged with the physician, nurse and other members of the healthcare team to discuss possible reasons why an agreement cannot be reached. Often, conflicts arise because of a lack of communication. However, if differences cannot be resolved, it is important that the patient, agent or family learn what resources the facility has to mediate and resolve conflict.

      Healthcare facilities are required to have a process in place for resolving conflicts over decisions about CPR. A social worker or patient representative may be a good source of information about what to do. The family should also ask to see a copy of the facility's policy on DNR orders. The policy should describe the facility's process for resolving conflict. For example, many facilities give patients and their families the opportunity to bring disputes before an ethics committee that can provide a neutral environment in which to mediate and resolve conflict.

    • Can a physician write a DNR order without consulting the patient?
    • Answer:

      Yes, in limited circumstances. If a physician feels that discussion of a DNR order would be harmful, a physician is not obligated to consult the patient directly before writing the order. In special circumstances, if a patient is incapacitated and an authorized decision maker is not available, a physician may, depending upon the facility's policy, write a DNR order if he or she believes that CPR would not be successful appropriate treatment given the person's underlying illness.

      In general, however, physicians are obligated to discuss a DNR order with a patient or his or her authorized decision maker, and must obtain consent before treatment can be withheld or withdrawn. Informed consent is a basic right of patients that must be respected by a facility's policy on DNR orders.

    • Will a DNR order remain effective when a patient is transferred between healthcare facilities, for example, from a nursing home to a hospital?
    • Answer:

      Yes. A person's DNR order should accompany him or her on every transfer. Once the person arrives at the new facility, a new DNR order may need to be written based on that facility's policy. It is important that family and friends monitor the transfer to ensure that the DNR order accompanies the person and is properly documented in the medical record at the new facility. A DNR order or other important documents like a living will and medical power of attorney can be misplaced or overlooked during a transfer.

    • Will a DNR order be honored during surgery?
    • Answer:

      Usually not. DNR orders often are suspended during surgery. Cardiac or respiratory arrest during surgery may be due to the circumstances of surgery and not the underlying illness, and the chances of a successful resuscitation may be better. DNR orders should be reinstated after a specified period of time following the surgery. It is important that the patient or decision maker talk to the surgeon in advance to make sure all parties understand what should happen in the event of an arrest during or shortly after surgery. The surgeon should also discuss how soon after surgery a DNR order will be reinstated.

    • Can a DNR order be revoked?
    • Answer:

      Yes. The patient or authorized surrogate can cancel a DNR order at any time by notifying the attending physician, who must then remove the order from the medical record.

    • What is a non-hospital DNR order?
    • Answer:

      Unlike medical facility DNR orders, non-hospital DNR orders are written for people who want to refuse CPR and are outside a healthcare facility, either at home or in a residential care setting. Also referred to as a pre-hospital DNR order, a non-hospital DNR order directs emergency medical care providers, including emergency medical technicians, paramedics and emergency department physicians, to withhold CPR.

      These orders must be signed by a physician and generally are written on an official form but, depending upon the state, they also may be issued on a bracelet, necklace or wallet card. Although honored by emergency medical providers, non-hospital DNR orders are not binding upon bystanders who may initiate resuscitative measures in an emergency.

    • Why are non-hospital DNR orders needed?
    • Answer:

      Emergencies demand an immediate response. Emergency medical service (EMS) personnel are trained to act quickly and to save lives. Once called to a scene, they must do all they can to stabilize and transport a person to the nearest hospital, including administering CPR if necessary. If a person wishes to refuse CPR in the home, he or she must have a non-hospital DNR order. Without a non-hospital DNR order, EMS will initiate CPR if a person is in cardiac or respiratory arrest. It is important to remember, however, that as long as a person has decision-making capacity, he or she can refuse any form of medical treatment, including emergency care.

    • Will all treatment be withheld from someone who has a non-hospital DNR order?
    • Answer:

      No. A non-hospital DNR order means "no CPR;" it does not mean "no treatment." If a person has a valid non-hospital DNR order, CPR is the only medical treatment that will be withheld. If a person with a non-hospital DNR order is suffering from any injury or problem other than cardiac or respiratory arrest, EMS personnel will do whatever is necessary to stabilize and transfer the person to the nearest hospital.

    • Will EMS personnel honor a living will or medical power of attorney if a person suffers a cardiac or respiratory arrest?
    • Answer:

      No. Generally, advance directives such as living wills and medical powers of attorney are not effective in a medical emergency and are not binding upon EMS personnel. There is no time in an emergency either to consult the directions in an advance directive or determine a person's underlying medical condition. Furthermore, EMS personnel are not authorized to evaluate an advance directive or make medical diagnoses.

      Once the person comes under the care of a physician qualified to evaluate the contents of a living will and instructions of a healthcare agent in light of that person's overall prognosis, any unwanted treatment that has been started by EMS personnel can be stopped.

    • Are non-hospital DNR orders governed by state law?
    • Answer:

      Yes. Many states have laws in place governing non-hospital DNR orders. With the growth of hospice care and the increasing desire of dying patients to spend their last days at home has come the need to protect people from unwanted emergency care. Non-hospital DNR laws allow qualified persons to refuse emergency resuscitative measures under certain conditions.

    • What should I do if my state does not have a non-hospital DNR law?
    • Answer:

      First, you should check with the State Department of Health and county EMS agency to determine if a statewide policy or any local protocols governing non-hospital DNR orders exist. If no statewide policy or local protocols exist, you can try to make private arrangements with your physician and local EMS agency. A physician may be able to write a DNR order on official stationery explaining its applicability to the non-hospital setting. In a small community, a physician also may be able to notify the local EMS agency about the situation and the DNR order, explaining the patient's wishes not to receive CPR. However, without a state law or policy governing its use, it is unclear if such an order would be legally binding for EMS personnel.

      If a home death is planned, the family should have instructions from the physician, hospice or home care program about what to do when the patient suffers cardiac or respiratory arrest. Generally 911 Emergency should not be called if the intent is to avoid resuscitation or transfer to a hospital.

      If a family wants to be certain that a loved one who is seriously ill would not be resuscitated against his or her wishes, they should resist calling 911 Emergency. To avoid allegations of abuse or neglect, the family should make prior arrangements with a doctor who can oversee their loved one's care and be available to sign a death certificate when the time comes, certifying that the death was expected and due to natural causes.

    • Who should consider a non-hospital DNR order and when?
    • Answer:

      Non-hospital DNR orders generally are intended for terminally ill persons who have chosen to die at home, or for people with a serious chronic illness for whom the success rate of resuscitation is very low. Depending upon the state law or policy, there may be restrictions on who can qualify for a non-hospital DNR order. Remember, these orders must be signed by a physician to be valid.

      A non-hospital DNR order should always be considered during discharge planning when a seriously or terminally ill patient leaves the hospital, particularly if the person had a DNR order during the hospital stay. These orders should also be considered for individuals who have chosen to die at home or who are enrolled in a hospice program. People who have questions and concerns about whether they qualify for a non-hospital DNR should consult a physician.

    • Where can I get a non-hospital DNR form?
    • Answer:

      Ask your physician or local hospital. If your physician or local hospital does not have the forms available, you should ask them to contact the State Department of Health or State EMS Agency to obtain them. Home care and hospice organizations also might be helpful for obtaining the forms. Some local organizations may make the forms available.

    • Can a non-hospital DNR order be revoked?
    • Answer:

      Yes. The patient, or the patient's authorized surrogate can cancel a non-hospital DNR order at anytime by notifying the physician who signed the order and by destroying the form and/or bracelet.

    • Is it ever appropriate to call EMS if someone has a non-hospital DNR order?
    • Answer:

      EMS should be called only if caregivers are unsure whether a person is experiencing cardiac or respiratory arrest and help is needed short of CPR. To avoid unwanted treatment and hospitalization, family members and close friends should plan ahead for their loved one's care.

      Good planning might involve enrolling their loved one in a hospice or visiting nurse or home care program. Doctors and nurses can provide valuable information and advice about how to care for a loved one who is dying and what to expect when death is imminent; sometimes they may be available to visit the home. If the family knows what to expect, they may feel more comfortable not calling EMS; instead they should make arrangements to call the doctor or hospice nurse and eventually, a funeral director.

    • What happens to a non-hospital DNR order when someone is taken to a hospital?
    • Answer:

      If a person is admitted to the hospital for any reason, it is important that the non-hospital DNR order goes with the person. If EMS personnel are involved, they should take the order with them in the ambulance, but it is still advisable for family members to bring a copy of the order with them. Although the admitting physician should write a new DNR order at the hospital, it is important that family members make sure that a facility DNR order is in place. Hospital personnel are sometimes unfamiliar with DNR laws or policies, and in an emergency, important papers can be overlooked.

    WebMD Medical Reference from the National Hospice and Palliative Care Organization

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