Enterprise Risk Management (ERM) Legal & Regulatory Patient Safety/Clinical Care Quality

Is Universal National DNR Possible?

A senior woman's hand signing a document

Most states have Do-Not- Resuscitate laws. However there are different requirements from state to state and not all DNR orders are honored between states. For example, in one state, there are two witnesses required whereas in another state the document must be notarized. Unfortunately for patients, this can result in healthcare facilities not being able to accept, and therefore honor, their DNR paperwork.

Other issues arise in honoring DNR papers. If a patient with a DNR needs surgery, such as a palliative procedure to reduce pain by reducing a tumor, anesthesiologists usually require suspension of the DNR for the pre-op, perioperative and post-operative time frame. The rationale for this requirement is that during anesthesia, patients are given medications that put them in an unnatural state and anesthesiologists want to be able to reverse those effects if needed. Otherwise, they believe they would be contributing to the patient’s demise. In Virginia a physician can suspend a hospital DNR order for a specific period of time such as pre-op, peri-op and post-op until discharge from the post-anesthesia care unit. The healthcare providers can reinstate the DNR order after the specified time frame.

No DNR Suspension

However, in the state of Virginia, a Durable (community) DNR order cannot be suspended but rather must be revoked and a new order written. The problem here is that perhaps the patient will not have capacity after their procedure to specify their continued desire for the order. In this situation, an advance directive would increase the chance that patient wishes would be honored. Unfortunately not all patients have both documents. Recently, after a lengthy discussion with a family member, it was suggested that the family consider not bringing in a patient’s DNR order for her outpatient surgery as it would require revoking and creation of a new order post-op.

We recently had an ethics discussion about a 91-year-old female stroke patient with severe dementia who was admitted from a nursing home with severe protein calorie malnutrition. A feeding tube had been declined due to high risk nature of patient’s condition. She had a PICC line in place and had been receiving IV fluids, which further contributed to heart failure. Unfortunately this patient did not have an advance directive and her son was struggling with what to do. If she had an advance directive, her wishes would be known, alleviating some of the son’s struggle as he would have known mom’s wishes.

Tattoo DNRs

These are a few of the difficulties we have encountered in trying to honor a patient’s DNR wishes. As an indication of how strongly some people want others to know their desires, some are now getting tattoos on their chest stating “Do Not Resuscitate.” Unfortunately, although this certainly visually illustrates their wishes, it does not translate into an acceptable DNR order. Healthcare facilities operate based on physician orders and plans of care.

If such difficulties are apparent to those of us in the healthcare industry, think about how challenging it is for those not in our industry. In an ideal world, we would have a universal document that is accepted throughout our nation to support a patient’s wishes related to end of life care. Unfortunately that does not yet exist. None of the above mentioned circumstances are easily addressed with our current systems.

Current DNR Recommendations

So, given all of these issues, what is the best way for patients to support the honoring of their end of life care wishes?  It is recommended that they get at least one document in place – an advance directive specifying their wishes and designating a decision maker whom they trust to follow their instructions if they lack capacity. Be certain that this advance directive is provided to the healthcare team and discussed with their physicians so that appropriate orders can be written and implemented. This requires that patients bring a copy of their advance directive with them when they are scheduled for healthcare services or actually carry a copy with them at all times. Healthcare facilities should scan these documents into the electronic health record so it can be readily available for future reference.

Until a national DNR become reality, healthcare professional should continue to help people become aware of the need for and best way to communicate end of life wishes.

For more than two decades, Heidi Harrison, BS, RN, CPHRM, has been a risk manager at Inova Health System, which serves more than two million people each year from throughout the Washington, DC metro area and beyond. Currently, she is also the chair of the ASHRM Forum Task Force, leading the team that writes, acquires and edits the submissions to share in the Forum.




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