Resuscitation. Self-Determination. Saving Lives.
The introduction of formal Do Not Resuscitate (DNR) orders in the late ’70s was a watershed moment in healthcare, emerging from the widespread adoption of cardiopulmonary resuscitation (CPR) in the ’60s. This shift highlighted the importance of patient autonomy and sparked a vital conversation about the right to choose one’s medical fate.
In this article, you can dig into what the terms DNR, CPR, and DNI mean, some common misconceptions, and the role of nurses in navigating these tough decisions.
What Does DNR Mean?
DNR stands for “Do Not Resuscitate,” but the term can be misleading since it only applies to cardiopulmonary resuscitation (CPR), not medication or other procedures.
Common Misconceptions about DNR Orders: What Is a DNR?
A DNR order is both a medical directive and a legal document that reflects a patient’s decision to forgo CPR while still allowing for other forms of medical care. However, many patients, families, and even healthcare workers still have some confusion around the meaning of Do Not Resuscitate, such as the following:
- Contrary to popular belief, a DNR order does not reflect a desire to end life. Many patients choose this option because they understand the low chances of survival, especially when facing terminal illness. Nurses view and respect the patient’s choice as informed decision-making.
- A DNR order means explicitly that a patient does not want CPR in the event of cardiac or respiratory arrest. However, it does not indicate a refusal of all medical treatment. Other interventions, including medications, antibiotics, dialysis, and palliative care, remain available.
- Moreover, a DNR order does not restrict care to comfort measures alone. Patients may still choose life-prolonging treatments, and discussions with nurses and other healthcare professionals can clarify their wishes.
By dispelling these misconceptions, nurses can foster clearer communication and empower patients and families to deal with troubling issues and make informed decisions about their healthcare preferences.
What Is the Difference between DNR and DNI?
To define the medical term DNR clearly, it is helpful to distinguish between the meaning of DNR and DNI (Do Not Intubate). DNI means that the patient does not want to be intubated or have a breathing tube placed if breathing stops but allows the use of chest compressions. A DNI is more limited in scope, but neither one means “do not treat.”
What Does “Resuscitate” Mean?
Regarding DNR orders and CPR, medicine defines the term “resuscitate” precisely as the implementation of medical procedures employed to restore breathing and heartbeat immediately following cardiac arrest. These procedures typically include chest compressions, artificial ventilation, and, in some cases, medications or electrical shocks.
Outside of the medical context, “resuscitate” may be understood as bringing someone back to life. In reality, resuscitation is only possible if the person is in cardiac arrest but has not yet reached the point of brain death and irreversible death. The definition of “resuscitated” needs to be clearly defined and understood in conversations with patients and their families.
How Many Patients Survive After CPR?
Another widespread misconception regards the probability of survival after CPR. The likelihood of survival after in-hospital CPR is only 12 percent—up to when the patient is discharged from the hospital. Of course, this varies by age and general health. And for terminally ill patients, even if they are strong enough to survive, the procedure does not cure them.
How Harmful or Painful Is CPR?
If CPR can save lives, why would anyone want an order not to be resuscitated?
According to the Cleveland Clinic, CPR is an aggressive intervention that often involves more than chest compressions and mouth-to-mouth breathing. The procedure can entail using powerful drugs or electric shocks (using an automated external defibrillator to get the heart beating again) or inserting a breathing tube into the airway (trachea).
Even in cases where a life is saved, the patient may suffer painful injuries during CPR, such as broken ribs and sternal fractures.
Some people with terminal illnesses, such as patients with advanced stages of cancer or individuals with other debilitating or painful medical problems, may not want to have CPR, even if that means they could die as a result. Deciding to have a DNR order can be empowering, making patients feel more in control of their lives.
Do Nurses Have a Role in DNR Decisions?
The American Nurses Association (ANA) clearly supports the active and sometimes decisive role of nurses in DNR decisions in their public position statement:
“Nurses advocate for and play an active role in initiating discussions about resuscitation with patients, families, and members of the health care team. Care for patients with do-not-resuscitate orders is no different from care for any other patient, including respect and advocacy for the patients’ preferences and values, promotion of well-being, and alleviation of suffering. Patients with do-not-resuscitate orders must not be abandoned, nor should these orders lead to any diminishment in quality of care. Nurses’ holistic view of patient and family care prepares them to collaborate with the patient, family, and health care team to promote informed decisions when do-not-resuscitate decisions are made.”
Nurses have a crucial role in decisions regarding Do Not Resuscitate orders, involving ethical considerations, patient autonomy, and collaboration with healthcare teams. Here are five key points regarding the role of nurses in DNR orders:
1. Advocacy and Ethical Guidance
Nurses are often the primary clinicians who advocate for the patients’ rights to accept, refuse, or terminate treatment, including resuscitation decisions. Nurses need to know not only the DNR acronym but also its medical and legal implications since they share legal and medical information with patients and their families, ensuring patients receive the support they need throughout the decision-making process. Nursing ethics, including the principles of autonomy, compassion, and respect, guide nurses in decision-making.
2. Education
Nurses educate patients by providing clear, accurate information about DNR orders and their implications. They help patients and families understand the benefits and burdens of resuscitation options, promoting informed decision-making.
3. Collaboration and Communication
Effective communication is indispensable. Nurses facilitate discussions among patients, families, and healthcare providers to ensure that everyone understands the implications of DNR orders and that patient preferences are respected. Communication can be particularly challenging with non-verbal patients.
4. Involvement of Patients and Families
DNR decisions should involve family members, especially when patients cannot make decisions due to their medical conditions. It is crucial for nurses to engage families in discussions about DNR orders to align treatment with patients’ values and wishes.
5. Continuous Review
DNR orders should be reviewed regularly, particularly if the patient’s condition changes or if there are shifts in the patient’s or family’s preferences regarding resuscitation.
The ANA Code of Ethics guides nurses in delivering ethical, high-quality care. This code of ethics is also essential for per diem nurses supporting patients and facilities nationwide. Nursing decisions about Do Not Resuscitate orders are guided by ethical principles, collaborative practice, patient and family involvement, advocacy, and ongoing communication, ensuring that the care provided aligns with the patient’s wishes and best interests.
So, Who Makes the Decision?
The patient has the right to self-determination and may request a DNR. The medical team may also initiate this conversation with the patient and/or the family. Either way, the patient’s wishes are usually the determining factor.
However, in some cases, doctors can also make DNR decisions when facing a critically poor prognosis or if the team considers that the patient will not survive CPR with sufficient quality of life. It’s important to realize there are many instances in which, despite a patient’s DNR order, the medical team may start CPR to appease the anxiety and wishes of family members.
In emergent situations where the patient is unconscious and the DNR status is unknown, CPR will take place. To avoid conflict, patients can prepare a living will or advance directive indicating their desires and decisions. Well-informed and proactive nurses may significantly assist in making decisions and ensuring proper documentation.
Find out more about how nurses deal with the human response to health conditions and life processes in “Understanding the NANDA Nursing Diagnosis List with Examples.”
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