Patients who are critically ill and potentially dying face overwhelming challenges, including a variety of intense emotions, loss of dignity and helplessness. A study published in the American Journal of Nursing shows that patients who have chosen a â€œdo not resuscitateâ€� (DNR) order may not receive the same patient care as others.1
The difference appears to be based on the interpretation of the order by individual nurses and doctors. A DNR order is an important consideration at any time in life when a person may not want extraordinary measures taken if their physical condition deteriorates.
Currently, Baby Boomers outnumber young children, resulting in a rising number of age-related health challenges that must be faced by providers and the community. In 2015, Mary Kruczynski, director of policy analysis at the Community Oncology Alliance, commented on the dichotomy between science and medical care, saying:2
â€œYet as science evolves from the macro down to the nano level, we have had some difficulty embracing a key concept: physicians can diagnose disease by molecular rearrangements using gene microarrays, and yet we as a society are unable to come to a common understanding that death is an inevitable continuum of life.
Every single living organism is destined, indeed genetically programmed, to die. And yet, despite all of our advances, neither the larger scientific community nor society as a whole is willing to initiate a sustainable debate around death â€” the only certain facet of existence.â€�
Whether a person is admitted to the hospital for an appendectomy, COVID-19 or a tumor, their physical condition can deteriorate to a point where resuscitation is necessary to maintain life. As you consider your options, this data demonstrates itâ€™s crucial that your wishes are well documented and communicated so they do not negatively impact care.
Study: DNR Interpretation Affects How Care Is Delivered
For more than 40 years, DNR orders have been a health care consideration. However, as recent research has demonstrated, not every health care professional has the same understanding of the order. Guidelines define the action as withholding cardiopulmonary resuscitation (CPR), which is reiterated in a position statement by the American Nurses Association. In it they stress:3
â€œPatients with do-not-resuscitate orders must not be abandoned, nor should these orders lead to any diminishment in quality of care. Language matters in promoting effective communication with patients, family members, and others.
Both health care providers and the public can be confused about the definition and implications of DNR (do not resuscitate) and associated terms such as comfort care, DNAR (do not attempt resuscitation), DNI (do not intubate), FC (full code), and POLST (Physicianâ€™s Orders for Life Sustaining Treatment).â€�
Confusion about how a DNR order may impact care, misinterpretation of the order and a nurseâ€™s perspective on care were all factors that played a role in the development of this study. The difference between definition and functional outcome has an impact a personâ€™s care in the hospital. The researchers wrote:4
â€œWhile the definition of DNR might seem straightforward, its interpretation in clinical practice can be complicated. In this study, most of the nurses understood the meaning of DNR. Yet their interpretations often indicated clinical situations in which a DNR order was misaligned with the plan of care or was misinterpreted as replacing it.â€�
Confusion about the definition and implications is exactly what researchers found when they examined care based on a person’s DNR designation. Direct care nurses from a large urban hospital participated in an open-ended interview to gather information.5
When the data were analyzed, the researchers found there were varying interpretations on how to carry out DNR orders that resulted â€œin unintended consequences.â€�6 The nurses also reported they perceived a variety of interpretations from other team members and patients. The researchers identified three key areas from the data:7
- The nurses could clearly define a DNR order but had a variety of interpretations for how care was specifically given.
- The nurses reported situations during which other health care members disagreed on how a DNR order might affect patient care.
- Family conflicts and confusion could arise when the patient’s condition changed, and some members would disagree about the status of a DNR order.
The researchers believe each of these perceptions increased the potential to change patient care, increased tension between health care members and set up potential challenges in role expectations.
Maureen Shawn Kennedy, editor in chief of the American Journal of Nursing, commented on the importance of the study, saying,8 â€œEveryone â€” nurses, physicians, and families â€” needs to be on the same page in understanding the level of care a patient will receive.â€�
What Is a DNR Order?
As Dr. Roger Seheult explains in the MedCram video above, a DNR order is not as simple as you may think. To define a DNR order, it helps to know whatâ€™s involved in a â€œfull code,â€� or a situation where a person will receive all measures to maintain life. As Seheult explains there are three main categories of action that can be taken:
- Most Invasive â€” Cardiopulmonary resuscitation (CPR), advanced cardiovascular life support (ACLS) and electric shock.
- Intubation â€” A tube is placed down a personâ€™s trachea to help them breathe or if their neurological status has deteriorated so they canâ€™t protect their airway. This also involves sedation.
- Medications â€” Vasopressors are medications given to help support a personâ€™s blood pressure.
Each of these strategies has side effects and possible adverse events. The most invasive of the procedures are most successful when a personâ€™s cardiovascular system needs immediate support after a trauma, and they are otherwise healthy.
In many hospital cases a code does not happen suddenly the way it does on television. Instead, a personâ€™s health may gradually deteriorate in the intensive care unit, so medications are needed to support blood pressure, dialysis to support kidney function or ventilation to support oxygen exchange. Finally, the heart may be unable to sustain function and stops.
This is why in-hospital CPR is not as successful. As Seheult explains there are three typical scenarios. In the first case, patients recover and no longer need support measures. In the second case, despite the teamâ€™s best efforts the patient doesnâ€™t recover and dies. In the third case, the patient doesnâ€™t get worse or better but appears to stay in a holding pattern on â€œlife support measures.â€�
Understanding the Different End of Life Choices
While these choices are not easy ones to make, they are important if youâ€™d rather your life is not maintained using extraordinary measures. People can choose the measures they want and donâ€™t want from each of the major cardiovascular support actions listed above.
People who do not want any measures taken have a DNR/DNI (do not intubate) order written in their chart. People who would like medications but not CPR or intubation have a modified DNR order, so all health care providers are aware of the patientâ€™s wishes.
Itâ€™s important that the right orders are written, and you understand and use the terminology used in your hospital to avoid any confusion. For instance, in some hospitals they use â€œallow natural deathâ€� (AND) to mean a patient wants only comfort measures to control pain and reduce discomfort.9
Each of these decisions are meant to define the type of care given during a health crisis when CPR, intubation or vasopressor medications may be necessary.
However, as the current study showed, not all health care professionals interpret the order in the same way, which means the general care you or a loved one receives may be different than if there wasnâ€™t a DNR order on the chart.
Advanced Directives and POLST
There are steps you can take to ensure the type of care you want is given. The first step is to have an advanced directive. These are legal documents that tell your family and health care providers what you want to help avoid confusion if you are too sick or injured to speak for yourself.
An advanced directive can help guide your care based on your wishes. The two most common types are a durable power of attorney for health care, which is sometimes called a medical power of attorney, and a living will.10
All states have different laws about advance directives, so itâ€™s crucial you are aware of your state regulations, so your advance directive is legally binding and followed where you live.11 You can get an advance directive form from your state bar association.
Before creating your directives, itâ€™s important to speak with your family and anyone you may name in a medical power of attorney. A health crisis is a confusing and challenging time for loved ones. Since they are the people making many of the decisions, itâ€™s helpful they know and understand the situation, wishes and fears that went into the decision making.
A living will is a document that is used to speak for someone who is unable to speak for themself, such as when a person is at the end of life or permanently unconscious. A medical power of attorney names an agent or proxy who has the legal right to make health care decisions when a person is no longer able.
Physician orders for life sustaining treatment (POLST) is another document that helps set a standard of care during a crisis that medical providers must follow. The form must be signed by a qualified member of the health care team. Emergency medical providers, like paramedics, must follow the orders on a POLST but are not bound to an advanced directive.12
Not all states have POLST forms. National POLST13 is a not-for-profit organization working to standardize the process in each state. In 2015, the National Academy of Medicine published a report that encouraged the creation of a program to meet national standards and in which they made â€œrecommendations to create a system that coordinates care and supports and respects the choices of patients and their families.â€�14
What Can You Do to Ensure the Right Care Is Given?
Advanced directives and POLST are legal steps you can take to ensure the right type of care is given. However, since DNR orders and advanced directives may open other decisions to interpretation, itâ€™s important that you educate others and advocate for yourself or your loved one if hospitalization occurs for any reason.
As the study demonstrated, some providers believe a DNR order may mean the patient is interested only in comfort measures, regardless of why they were admitted or their current medical status. However, the intent of a DNR order does not extend beyond making decisions about intubation, CPR and vasopressor medications.
It may be necessary to communicate this to health care providers to assure they are well aware that you or your loved one wants â€œeverythingâ€� done, short of specific decisions outlined in an advanced directive, POLST or DNR/DNI order.