There was a story about a couple who just moved to retire in Florida. The husband, named Ken (not his real name) was diagnosed with a serious heart condition, along with some kidney and metabolic problems. The only way to fix his heart ailment was through an open-heart surgery.  Ken seriously thought about the procedure and discussed it with his wife and children. He was determined that he did not want the surgery. He was 87 years old. He decided upon consultation with his cardiologist that the risks of the operation outweigh the benefits. He filled out his advance directive citing that he was resolved to die without resorting to surgery and other disproportionate interventions.  Ken also filled out the DNR form along with the advance directive.

DNR is usually prepared in a different form.  It should not be assumed to assign an automatic DNR to patients who have an advance directive.  DNR is a legal order signed by a physician telling health care providers, including 911 rescuers or Emergency Medical Technicians (EMTs) not to perform Cardiopulmonary Resuscitation (CPR) or Advanced Cardiac Life Support (ACLS) to a patient in an event of cardiac arrest and respiratory failure, and when vital signs are not evident.

DNR order form must be readily available to EMTs

One day, when Ken went fishing with his friends, he suddenly fell and collapsed.  Ken’s heart stopped, and his respiration failed. The EMTs arrived at the scene and they immediately looked for a DNR form. They could not find one so they resuscitated Ken.  Meanwhile, someone called his emergency contact, which was his wife. She arrived at the scene, bringing with her Ken’s DNR form, but it was late.  Ken was already on his way to the hospital.

For people who have frail health condition like Ken and are certain that they do not want to be resuscitated, filling out an advance directive indicating DNR is not enough.  They are going to appropriately put in in writing using the proper DNR forms.  The DNR order form must be placed in a prominent place in the house or be readily available when the person is not in a hospital.  EMT’s may be obliged to resuscitate a person if a DNR order is not available. If the EMT’s have the appropriate document, they would have known Ken’s wishes and they would not attempt to resuscitate him.

Cardio Pulmonary Resuscitation (CPR) is an emergency rescue technique that covers a range of interventions that include resuscitation and chest compressions to restore heartbeat and breathing. CPR can help maintain the circulation of oxygenated blood throughout the brain and body until the heart rhythm can be restored.  In hospitals, CPR involves the use of mechanical ventilation, intubation of breathing tube, cardioversion or electrical shock and administration of medications. This kind of CPR is called Advanced Cardiovascular Life Support or ACLS.^[1]

It is important that patients and their families talk with their physicians to have precise information about the risks and benefits of CPR. CPR techniques have improved over time.  It has a good chance and a high rate of success for healthy people who suffer from cardiac arrest or respiratory failure. Hence, people with good physical health have a moral obligation to accept this intervention because CPR’s benefits outweigh the risks in their case.

 CPR is not obligatory for people with debilitating conditions

CPR is not obligatory for people whose overall condition is deteriorating. The likelihood of CPR meeting its immediate goal of restoring heartbeat and breathing for frail and terminally-ill individuals is low.  If one’s prognosis is likely to be poor, such as dying from untreatable cancer or other terminal illnesses, CPR can be an invasive procedure and can offer no significant benefit for him or her. Chest fracture can also result from chest compression. This is a typical concern for the elderly who have frail bones. Hence, what is ordinary and morally obligatory for a healthy person becomes extraordinary and morally optional (and even unreasonable) for people who are frail, elderly or those with debilitating conditions.^[2]

A decision to forego CPR may support the desire of patients to die at home or to forgo other life-sustaining or life-prolonging treatments and procedures. The Florida Statute defines life-prolonging procedure as “any medical procedure, treatment, or intervention, including artificially provided sustenance and hydration, which sustains, restores, or supplants a spontaneous vital function. The term does not include the administration of medication or performance of medical procedure when such medication or procedure is deemed necessary to provide comfort care or to alleviate pain^.”[3]

Many people would rather allow death to take its course than resort to aggressive treatments and interventions when no recovery is expected from their condition, or when undue burden and pain may result from such interventions.

Like all health care decisions, a decision about resuscitation should be based on a combination of the person’s personal values along with the medical facts and options for treatment.  If a DNR is requested, “the condition of the patient must be such that the intervention would be of no significant benefit.”^[4]  A DNR order does not restrict physicians from providing interventions that are necessary to alleviate pain and provide comfort to a patient. If these conditions are met, DNR orders and procedures are aligned with the teachings of the Church.

If a person’s death is imminent and he/she is unable to communicate, a living will or advance directive that makes his/her wishes known may be used to put a DNR order in place. The appointed healthcare surrogate can also authorize a DNR order, which is consistent with the principal’s known wishes.

It is important to fill out appropriate DNR forms required in every state or territory

There is a special form that must be filled out for a DNR order to be honored in different places.  The forms and DNR policies are outlined by statutes of a state or territory.  In the State of Florida, resuscitation may be withheld or withdrawn from a patient by EMTs if evidence of an order not to resuscitate by the patient’s physician is presented to EMTs. A person who is not hospitalized fills out a DNR adopted by the state.  An order not to resuscitate must be on the form to be valid. The form must be signed by a physician, the patient, or the health care surrogate if the patient is incapacitated. In the State of Florida, the form must be printed on a yellow paper.^[5]

It may be helpful to secure a medic-alert bracelet, anklet, or necklace to make DNR wishes immediately apparent. These markers are not substitutes for the DNR form. They are only used to alert emergency rescue personnel that a person opted for DNR and has signed a DNR form.  The form must be readily available by putting in it in a visible and prominent area of the house.

The patient can also use the miniature version of the form, (found in the bottom of the form). The miniature form can be separated and laminated and must be carried (or attached) to the person wherever he/she goes.^[6]  It is important to follow the policies or protocol of the state concerning DNR orders. For instance, in Florida, an out of state DNR form will not be accepted. It is important to fill out a Florida DNR order form for the duration of the stay in the state.^[7]  You may inquire with your physician or the health department on the details of out-of-hospital DNR orders.

______________________________________________________

[1] Albert R. Jonsen et. al., Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 8th ed, New York: Mc Graw Hill Education,33.

[2] David Kelly, Medical Care at the End of Life: A Catholic Perspective. Washington DC: Georgetown University Press, 2007, 8.

[3] See The Florida Statute, Healthcare Advance Directives. 765.101. (12), available at http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0700-0799/0765/Sections/0765.101.html, accessed on February 1, 2018.

[4] Rev Albert S. Moraczewski, “Do Not Resuscitate Orders,”  in Catholic Health Care Ethics: A Manual for Practitioners, Philadelphia, PA: National Catholic Bioethics Center, p 211.

[5]  See The Florida Statute, Title XXIX:  Public Health, Chapter 401.05, 3a: Denial of Emergency Treatment; Civil Liability. http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400-0499/0401/Sections/0401.45.html, accessed on January 15, 2018.

[6]  See The Florida Administrative Code 64J-2.018: Do Not Resuscitate Order (DNRO) Form and Patient Identification Device.

[7] See Florida Department of Health, Frequently Asked Questions on DNR No. 12. http://www.floridahealth.gov/about-the-department-of-health/about-us/patient-rights-and-safety/do-not-resuscitate/faq-page.html#individual