Introduction:
Resuscitation refers to the procedure of bringing someone back to consciousness when they faint. It involves techniques like mouth-to-mouth breathing, chest compressions to revive the heart, giving an electric shock, using breathing tubes to facilitate airway opening, etc.
What Is DNR?
It is an order set up before an emergency. It allows the healthcare provider to choose whether or not to give cardiopulmonary resuscitation (CPR) to the patient, irrespective of the patient’s condition. CPR stands for cardiopulmonary resuscitation, and it is a life-saving procedure done when the heart stops beating; this procedure facilitates spontaneous blood circulation restoration. CPR typically involves chest compression in conjunction with artificial ventilation. During DNR, other treatments or alternative therapy will not be provided. The doctor will take the patient's permission or consent, if not possible, then a proxy from the patient's caretakers before writing the order.
Because CPR cannot be given, all other resuscitative measures, such as electric shocks and artificial respirations, will also be avoided. This has been useful in preventing unnecessary and unwanted invasive treatment at the end of life. Also, the success rate of CPR near the end is shallow.
What Are the Side Effects of Resuscitation?
Even if the patient is successfully resuscitated, they may have some physical limitations and long-term fatalities, such as broken ribs, punctured lungs, a damaged heart, or brain damage. In addition, the risk increases with the increased duration of CPR.
How Is a DNR Order Created?
Nowadays, Allow Natural Death (AND) is becoming a preferred term instead of DNR to emphasize that the order allows natural consequences of a disease or injury and highlights ongoing end-of-life care.
Patients who want a DNR order inform their doctor or health care team. The doctor will follow the patient's wishes, else:
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The doctor may transfer the patient's care to another doctor.
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If a patient is in a hospital or nursing home, the doctor must agree to settle disputes to follow the patient's wishes.
The doctor then will fill out the form for the DNR order in the patient's medical record if in the hospital.
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In a non-hospital environment, the doctor can advise the patient on how to get a wallet card, bracelet, or other DNR documents.
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Standard forms may be available from the patient state's department of health.
If the patient changes their decision, reach out to the respective doctor. For security reasons, destroy any documents that include the DNR order.
What Are the Different Types of Orders?
Two types of orders are as follows:
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No Code: An order to discontinue resuscitation or not to revive in a hospital is known as no code. No code should be differentiated from a full code or code blue, which means that every effort should be made to resuscitate a patient anyhow.
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Allow Natural Death (AND): The Allow Natural Death (AND) order ensures that only comfort measures—such as administering painkillers and easing other symptoms—are used. It includes discontinuing or withholding resuscitation, feedings through artificial means, fluids, and other actions that will prolong a natural death. These orders are typically used for terminally ill patients.
What Are the Rules for DNR Order?
DNR orders vary from state to state, particularly regarding out-of-hospital care like an ambulance. Some states have standardized forms; if the order is not written on that, it cannot be considered. Some states are less concerned and honor any clear DNR order. Despite the format or the state, DNR orders follow the same general rules always; to be valid.
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A doctor should write it rather than state it verbally. There are some exceptions to this rule, such as an emergency physician can order an ambulance crew to stop or withhold resuscitation over the phone.
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A doctor should sign it. In cases where a nurse takes orders over the phone, the doctor has a deadline to verify and sign the declaration physically.
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Should include the patient's name and date. Orders may expire after a stipulated period of time, or the doctor may have a deadline to follow up.
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Even if a DNR order is not expired, especially in older patients, an order may evoke a caregiver to revisit the decision.
What Are the Ethical Implications of DNR?
The inconsistent application of DNR orders indicates that some patients may receive lesser care once healthcare providers are informed of the DNR order. A DNR order does not mean withholding all the treatment. It is just an order not to revive. Even the hint of DNR can result in many untoward reactions. Therefore, discuss the options with the doctor and family when everyone is calm and rational, hopefully sooner rather than later.
While analyzing perioperative DNR orders, four ethical concepts are essential.
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The first principle is non-maleficence, which stands for "first, not harm."
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The second concept is goodwill, or performing a good, moral act towards the patient.
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The third principle is patient autonomy, which is a predominant principle in ethical medical decision-making.
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The fourth principle is distributive justice, in which a society can provide medical resources to those best able to benefit from them.
Why Would a Patient Choose to Have a DNR Order?
Patients tend to go for DNR orders when they suffer from a terminal disease such as cancer or dementia. The patient may choose a DNR order whenever there is a poor prognosis and a lower survival rate with a higher chance of heart, lung, or brain damage if resuscitation is done. Some patients decide to have a DNR order because they do not want to be on life support when their time is running out because the possibility of pain and harm from CPR is frequently greater than the benefits.
Conclusion :
A patient may have difficulty discussing a DNR order and feel like giving up. Patients can take charge of their end-of-life plans while still being able to do so and understand the rules governing DNR orders. Even if patients opt for a DNR order, they have the right to change their minds, reverse the order, and request CPR.
