End-of-Life Documents: A Reminder for DNR

Posted on March 7, 2023

There is nothing like death, especially an unexpected death of a neighbor to give pause, and appreciation of the need for each of us to have an Advanced Care Plan in place. While I do, my husband does not, and, thank you very much, certainly does not want to think about, much less discuss or create one. Our neighbor’s recent passing has served to provide an opportunity (albeit) one, if not the most unwelcome conversation in the Dube household of late. I reminded him, in other areas of our

There is nothing like death, especially an unexpected death of a neighbor to give pause, and appreciation of the need for each of us to have an Advanced Care Plan[i] in place. While I do, my husband does not, and, thank you very much, certainly does not want to think about, much less discuss or create one.

Our neighbor’s recent passing has served to provide an opportunity (albeit) one, if not the most unwelcome conversation in the Dube household of late. I reminded him, in other areas of our life together, he has, and continues to made significant decisions – finance being one – that impacts both of us.

At some point in our lives, we may not be able to make health care decisions for ourselves. However, there are documents we can, and should prepare that will express our wishes and guide decisions others may need to make on our behalf.

Back to the task at hand, I appealed to his logical and analytical side observing that, planning for control over age related health changes is as significant than other plans, particularly finances. I was beginning to gain some traction.

Still, having lived with this man for many years, and understanding, I could easily derail our conversation by tackling all end-of-life documents: Living Will, Power of Attorney for health care (POA), Physician Orders for Life-Sustaining Treatment (POLST) and Do not Resuscitate (DNR), I chose to start with DNR.

The primary goal of having any one of the advanced care plans in place, is to assure our wishes and needs for dignity and control over life until the last breath. I began by asking him in the type of medical treatment he wanted or didn’t want in the event he was in some type of accident that resulted in cardiac arrest. He simply stared at me.

I forged ahead, explaining even though CPR can save lives, someone like myself who has participated in her share of CPR “codes” on a good number of patients, explained the combination of chest compressions and resuscitation, the use of powerful drugs and/or electric shock to get the heart beating again and almost always involving the insertion of a breathing tube, can leave a person suffering painful injuries, possibly leaving that person in worse condition, once resuscitated.

I continued, letting him know a DNR is ordered by a physician, while usually when someone is seriously ill. This was his opening. “Then why do I need to do this now,” he asked. I reminded him with amount the traveling we do . . . what would happen if he was in a terrible traffic or other type of accident. I expressed my belief that everyone should have a DNR.

I also explained there are two different kinds to keep in mind when having a conversation on this topic with your physician. A DNR Comfort Care (DNRCC) means that person receives care that eases pain and suffering, but no CPR or other emergency measures to save or sustain life. The second is DNRCC – Arrest which requires the patient receive standard medical care until the heart or lungs stop working or shut down.

Progress made. While his DNR is not yet in place, he tells me he has made a decision to “set it up.” I am confident he will raise the question with his physician during this next annual physical exam.

Other things to know about DNR

DNR does Not mean “Do Not Treat.” Rather it means only that CPR (Cardio Pulmonary Resuscitation – chest compressions, mouth-to-mouth resuscitation, heart drugs and a breathing tube - will not be attempted. Other treatments (for example, antibiotic therapy, transfusions, dialysis, or use of a ventilator) that may prolong life can still be provided. Depending on the person's condition, these other treatments are usually more likely to be successful than CPR. Treatment that keeps the person free of pain and comfortable (called palliative care) should always be given.[ii]

All states provide for special DNR orders that are effective outside of hospitals, wherever the person may be in the community.

These are called out-of-hospital DNR orders, Comfort Care orders, No CPR orders, or other terms.

Generally, they require the signature of the doctor and patient (or patient’s surrogate), and they provide the patient with a visually distinct quick identification form, bracelet, or necklace that emergency medical services personnel can identify.

These orders are especially important for terminally ill people living in the community who want only comfort care and no resuscitation if their heart or breathing stops. Living wills and health care powers of attorney are not generally effective in emergency situations. Additionally, first responders are almost always required to initiate life support unless a valid DNR order is in place and presented to them.[iii]

Keep in mind for when you travel!

Know the requirements of the states where you travel. There are different requirements from state to state and not all DNR orders are honored between states.

For example, in one state, there are two witnesses required whereas in another state the document must be notarized. Unfortunately for patients, this can result in healthcare facilities not being able to accept, and therefore honor, their DNR paperwork.[iv]

Questions to think about related to DNR:

1. Wear a bracelet showing your DNR status? It’s a personal choice. You can always re-evaluate should your health status change.

2. How will you store your DNR so others can find it in an emergency? Have paper and electronic copies for your phone and/or wallet, or you may want to laminate a copy for your wallet or purse.

3. Who will you share your DNR with?

4. Can you change your mind? Of course. Just write VOID across the version you want to change and start fresh. Don’t scribble notes and initial them, best to start fresh. Ask for help if necessary.

Then distribute to others, starting with your doctor. Explain your changes. Ask those you have provided with a copy of your DNR to destroy originals or to copy them on the voided version you create.

There should be considerable discussion about wants and expectations when end of life is inevitable. Having THAT TALK, while difficult for some, leaves no doubt as to that person’s wishes and expectations.

[i] A Complete Advanced Care Plan includes a Living Will, Power of Attorney for health care (POA), Physician Orders for Life-Sustaining Treatment (POLST) and Do not Resuscitate (DNR) orders. Of these forms the most confusing and misunderstood are DNR orders and POLST.
[ii] Physician Orders for Life-Sustaining Treatment (POLST). Merck Manual, Consumer Version. https://www.merckmanuals.com/home/fundamentals/legal-and-ethical-issues/do-not-resuscitate-dnr-orders
[iii] Ibid
[iv] Heidi Harrison, CPHRM. Is universal National DNR Possible? May 23, 2018. https://forum.ashrm.org/2018/05/23/is-universal-national-dnr-possible/