Shay Jacobson, RN, MA, NMG, LNCC, CNLCP
Weronika Dorman, LSW
The DNR is DOA
The simple DNR order has for many years been the instrument used in Colorado for notifying emergency responders that a given patient wishes not to receive Cardiopulmonary Resuscitation. This straightforward document was typically posted on the refrigerator in private homes and was not consistently incorporated into a patient’s formal medical chart.
Now there is something new. The overall approach to the documentation of end-of-life wishes has changed and, as it turns out, the changes come for good reason. The old DNR form was not really effective for a number of reasons.
The successful execution of a DNR order rests in large part on a rather significant conversation between physician and patient. Not surprisingly, this is not an easy conversation to initiate and, in many cases, doctors were not doing it. Also contributing to an obstructed process were the following factors:
- Family members disagreed about whether or not a DNR should be executed, resulting in a stalemate and no signed document;
- A verbal agreement to deny DNR was reached, but the actual document was never completed and/or signed;
- DNR discussions were not initiated until the patient’s loss of decisional capacity rendered them incapable of participating in the conversation;
- In some cases, patients’ properly executed DNR orders were not followed;
- Physicians did not inform patients of the many consequences of CPR (i.e. injury), making an informed decision far more difficult;
- Our medical culture revolves around rectifying issues and sustaining life, not standing down when a patient is coding;
- Our healthcare payment system, until recently, rewarded volume and intensity of care, making it financially lucrative for medical providers to resuscitate patients.
The Truth About CPR
Unbeknownst to most patients is the fact that CPR, in cold, hard, reality, is not very effective.
When CPR is administered in the hospital, survival rates range from 8-40%, and only 10-20% survive to discharge (meaning they code again or suffer some other reversal and die before achieving discharge from the hospital). Negative neurological outcomes (i.e. brain damage) are exhibited in 86-93% of surviving patients.
Out-of-hospital CPR success rates are even worse. Only 7-14% of adults who receive CPR in a non-hospital setting survive.
Mechanical CPR results in injuries (rib fractures, damaged airways and internal bleeding, to name a few) in 91.4% of patients studied.
Patients who watch a lot of television may, however, have a completely different understanding of CPR and its success rates. Television portrayals of CPR tend to feature young patients who have experienced cardiac arrest as a result of trauma, and 75% of those TV resuscitations result in survival. In real life, of course, survival rates are much lower and recipients of CPR are generally older patients with chronic health and lung diseases.
It has been reported that some medical providers, particularly when confronted with a frail, elderly patient, will perform CPR but in a reduced form. Known as “slow codes” or “show codes”, these gentler proceedings permit family witnesses the sense that something has been done without requiring first responders to fracture the ribs of an aged and seriously ill patient who likely will not survive.
The New DNR/MOST Document
The new DNR/MOST document is an actionable medical order that becomes part of a patient’s chart. There are several changes from the recently abandoned DNR form, including the following:
- The signer need not be a physician. While physicians will likely remain the primary signers of DNR/MOST documents, it is also permissible for an advanced practice nurse or a physician assistant to sign;
- The patient can designate one of three levels of treatment – comfort measures only, limited additional interventions and full treatment;
- There is a section on the DNR/MOST devoted to the patient’s wishes concerning administration of antibiotics. A patient can choose no antibiotics and for physicians to use other measures to relieve symptoms, to use antibiotics when comfort is the goal or to allow for the use of antibiotics as treatment.
- There is a new section devoted to the patient’s wishes concerning artificially administered nutrition and hydration. A patient can choose no artificial nutrition/hydration by tube whether or not they have executed a Living Will, a defined trial period of artificial nutrtion/hydration by tube or long-term artificial nutrition/hydration by tube. Additionally, if there is a Proxy by Statute as the decision maker, the proxy cannot decline artificial nutrition/hydration by tube without the approval of an attending physician and a second physician trained in neurology certifying that the process would only prolong the act of drying and would not assist in restoring the patient’s health.
The DNR/MOST document is intended for those whose death or loss of capacity in the next year would not be unexpected. It is not intended for use by those with disabilities or stable chronic medical decisions.
The new form should be used from this point forward. However, it is important to note that DNR orders executed in the past, and still on the old form, remain valid.
DNR/MOST versus POA
A DNR/MOST document directs initial treatment in a medical emergency. It does not allow for other treatments to be rendered or withheld, and cannot possibly foresee or apply to every medical scenario that might present itself. The patient’s Medical Durable Power of Attorney will be called upon to make decisions after the patient’s choices regarding CPR, antibiotics and artificially administered nutrition and hydration are honored, one way or the other.
Emergency responders cannot limit treatment on the strength of a Power of Attorney document alone. While the POA may point to the patient’s overall orientation toward life-sustaining care, it does not specifically apply to a cardiac arrest scenario in which CPR is required.
Key Issues and Concerns
Though widely viewed as an improvement over the old form, the new DNR/MOST document is not without its potential shortcomings and concerns. A number of issues have already been raised and have not been fully resolved as of this writing:
- If emergency responders are not aware of the existence of a DNR/MOST for a residential patient and none is immediately apparent, do they have a duty to search for one when a medical emergency is underway?
- Oregon mandates use of an electronic registry for MOST adopters but, again, do emergency responders have a duty to search the electronic registry en route to a coding patient’s home?
- Health care providers are required by law to honor treatment choices and are protected from liability if, in good faith, they honor the instructions set forth by the patient. The question has been posed, however, as to whether or not EMS providers are liable if they unwittingly administer treatment that is not wanted.
- DNR/MOST documents, like many others, open the door to abuse. Family members acting on behalf of an incapacitated patient might push for denial of treatment when, in fact, the patient communicated to them a desire to be resuscitated before losing capacity.
Why the Change?
Taken in sum, it appears that the changes reflected in the new DNR/MOST document are designed to facilitate the discussion of end-of-life wishes and broaden the scope of practitioners who can legally carry out the conversation and sign the document. The designers want to expand the likelihood that patients will be aware of their resuscitation options and execute documents that will reduce the incidence of unwanted and sometimes injurious treatment.
As 76 million Baby Boomers age into their senior years and face end-of-life decisions, the new DNR/MOST will afford them more choices, a greater voice, and the opportunity to direct the manner in which their final days are managed.
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