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DNR Codes and Levels of Care – Understand Before They’re Needed

DNR Codes and Levels of Care – Understand Before They’re Needed

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Many family caregivers of seniors will, at some point, have to answer the question “does your loved one have a DNR?

Too often that question will come at a stressful time, during a medical emergency.

What does that mean?” you may ask.

You won’t have to ask that, though, after you read this article.

DNR (Do Not Resuscitate), often referred to as “no code,” is an advance directive document that guides medical personnel to NOT perform CPR or otherwise try to revive your loved one if their heart is stopped.

If your senior loved one does not have a DNR in place, they are considered to be a full code and will receive all aggressive measures if their heart or breathing stops.

As a family caregiver you might be asked about their code status during an emergency — either full or no code or some level in-between.

A DNR advance directive is used only when the person is unable to communicate their own wishes and someone else needs to step in to direct their care, otherwise they will be asked to direct their care themselves.

CPR, cardiopulmonary resuscitation, is a technique that is used to reestablish a person’s heart rhythm and breathing, shocking the heart back to a normal beating rhythm. It can involve chest compressions, rescue breathing, defibrillation, medicine to stimulate the heart function, mask ventilation and intubation for mechanical breathing (also known as life support).

Details About DNR Orders

A doctor is required to sign a DNR advance directive to be placed in your senior loved ones medical record, unlike a living will which requires a signature of the person involved and possibly a witness. A new DNR is required upon each hospital admission, including transfers between facilities.

It is important to know that many EMS (emergency medical personnel) are not allowed to honor a DNR order unless specific to that state and properly executed. For example, some states have a DNR document for use by EMS and then another one for the hospital.

A physician order for life-sustaining treatment (POLST), which covers out of hospital DNR orders, may be available in your state. There are also bracelets or documents kept on the refrigerator to alert first responders or your senior’s wishes.

More and more people have created advance directives that will dictate what type of care they desire at the end of life. The number of older adults who are executing their advance directives, especially a DNR order, is increasing.

Unfortunately, many have not spelled out their wishes, leaving family caregivers to make these decisions.

DNR Expresses Wishes

A DNR tells the medical team that your senior loved one wants to die naturally without heroic measures of ventilation, intubation, or vasopressor support.

A DNR does not mean “do not treat” if a condition arises that could benefit from treatment such as IV fluids, antibiotics or oxygen.

While age should not be a determining factor in making a decision for a DNR order, for many older adults, particularly those who are already frail, performing CPR can be futile. Even if CPR is effective, the heart or lungs will potentially fail again.

Not only will it possibly not prolong their life, it can be damaging to an older person.

CPR can result in painful injuries or a loss of functional status after the CPR is performed. It is not unusual for fragile senior’s ribs to be broken and damage caused to internal organs during chest compressions. Adverse outcomes, such as hypoxic brain damage and increased physical disability, can result.

One report states that CPR is successful in only 20% of the cases.

Types and Levels of DNR Orders

There are different degrees of medical intervention, depending on the policy of the hospital or nursing home. It is a good idea to ask the facility for their policy regarding different levels of DNR care so you clearly understand the process when needed.

Some facilities use terms to describe how they handle DNR levels such as:

  • comfort care – only comfort will be given in the event a person’s heart stops beating
  • comfort care arrest – may use life-saving measures before the heart stops beating but only comfort measures once it stops
  • specified – written by doctor, dictates which methods can or can not be used, such as Do Not Intubate but can do chest compressions

Other facilities, especially long term care facilities, can define different levels of treatment in the event that a medical emergency occurs. You might see something like this in your care home.

Level 1:  Stay in the facility and be kept comfortable, but not given antibiotics or other medications to cure you.

Level 2:  Stay in the facility and receive all medications and treatments possible within the facility.

Level 3:  Be transferred to a hospital from a nursing facility but not given CPR or taken to intensive care.

Level 4:  Be taken to a hospital and given all possible medical interventions. Do everything possible.

Level 1 and 2 allow someone to die naturally in familiar surroundings.

Some states may use different terms such as these:

AND – Allow natural death, used in end of life situations to be clear that an end is anticipated and the natural consequences of the condition are allowed to proceed

DNAR – Do not attempt resuscitation, this should be accompanied by specifics of which forms of interventions can or can not be used if the heart ceases beating

We prepared a Types and Levels printable version for use in speaking with senior loved ones and to keep handy should it be needed in the nursing home or hospital.

Executing Advance Directives

These documents should be executed and a healthcare power of attorney designated well before they are needed. During a medical crisis our senior loved ones may not be able to communicate their wishes to the healthcare team or family members and it will be too late.

An established healthcare power of attorney can make these decisions on one’s behalf following their advance directives.

It is a good idea to be sure that any power of attorney has been briefed about wishes and has a copy of the advance directives.

All family members should know who the power of attorney is so that there will be no confusion when the times comes that decisions are needed.

Your senior’s advance directives can be changed at any point in time if there are changes in their desires or the person they wish to make decisions on their behalf.

This can be a sad and uncomfortable topic to think about and discuss with our loved ones, but dying with dignity can be achieved when our healthcare wishes are expressed, no matter what our senior loved ones decide.

6 Responses to DNR Codes and Levels of Care – Understand Before They’re Needed

  1. omg alright so this is exactly how asinine I am, midway through reading through your post I dropped my cup of coffee on my desk and closed the site in error and I could not locate your internet page once again until 4 days later on to finish reading where I left off since I forgot how I linked to your web site in the first place haha in any case it was worth the wait..cheers 🙂

  2. I was listening to some comments on TV on this subject and these thoughts occurred to me!
    So many health expenses now are folks who were meant to pass years ago! The more I reflect o. This subject it seems to me ( I’m 75) and Level 1 and 2 in the DNR ratings sound good to me. It would seem to me at my age I have had the best of this world and would like to leave when I am meant to go rather than years later hooked up to unbelievable pipes and needles and thereby leaving my space for literally and financially others who would benefit by a second chance! I have had a wonderful life and certainly hope the end isn’t in sight but if it is! I would rather leave naturally. We need to be able to choose assistance should we be unable to carry the load any longer! Wish I could stand on rooftops and shout that this is such an important issue!
    Thank you

  3. My mom pass in 2003. She didn’t have an DNR I had too fight my family on this my own older sister my brotherinlaw.It was bad! So me and my othe sister do have an DNR.

    • Thanks for sharing Cathy! It can be more difficult when there are no advance directives for seniors when siblings and family members don’t all agree. We never realize it until it happens to us! We are happy to hear that you and your sister have taken steps to make your wishes known!

  4. After crossing a milestone of their development adults become children again. They are to be treated alike. We do not allow our children to make decisions about DNR even if they PhD at 9 years of age (after mental deterioration seniors should also not opt for it). More appropriately saying, in old age (depending on mental and physiological status) we need to take measures to keep our parents ALIVE through care and services just the way they did for us in our infant-age. Today, at 40 I am strongly against DNR, I may change in a few decades, but keeping me alive or letting me die will become a decision-making question for my adult child :).

  5. I agree with Barbara. We were never meant to live this long. Is it really living when you’re in bed 24/7 hooked up to tubes? Or is it just existing? I am the SOLE caregiver of both parents who have suffered paralyzing strokes. Tahir, it’s insane that your argument is we need to do for our parents because they did for us when we were infants. Yes, it is our responsibility as children. But it’s also our responsibility to take measures into OUR own hands. Too many physicians are reactive when we should be proactive. We only cure the symptoms, not the disease. My parents are long gone mentally, but only here physically. I can’t even have a conversation with them. I have had to quit my job, sell my home and possessions, move into their house, to take care of them. We are on year 10 of non-stop care. I have no help, no siblings, no family. I’m completely burnt-out. Sometimes I want to cash out my savings, get in my car, and drive off. Every night I wish for their peaceful passing in the night.

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