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.