Beware the DNR order

This post is for those of us involved in caring for ourselves or others. (If you don’t give a sh*t about anyone, don’t read on.) It comes from a blog post by a highly credentialed physician and professor of medicine.

“DNR” is supposedly just about employing CPR. Even that was somewhat surprising, but facts about how it’s used can be very upsetting:

And it’s not just in the midst of a disaster that physicians mistake “DNR” for “Do Not Treat.” Study after study has shown that physicians say they would not administer a whole variety of treatments to patients who are DNR. One representative study of 241 physicians found that they were far less likely to agree to transfer a patient to the intensive care unit or even to perform simple tests such as drawing blood.

Most recently, physicians and nurses caring for pediatric patients also told interviewers that in practice, DNR means far more than just do not perform CPR. In this survey of 107 pediatricians and 159 pediatric nurses in a hospital setting, 67% believed a DNR order only applies to what to do after a cardiac arrest—but 33% said it implied other limitations. And 52% said that once a DNR order is in place, a whole host of diagnostic and therapeutic interventions should be withdrawn, over and beyond CPR, and a small but disturbing minority, 6%, said that a DNR order means that comfort measures only are to be provided.

Note: comment 1 below draws our attention to the possibility of state variations on a DNR order. In addition, some DNR forms are part of a living will, where you specify more about what is wanted. So it is worth checking out what is available. The focus of this post is to say ‘DNR’ may not be understood as you want it to be.

I’m reminded here of the Wiittgensteinian point that you won’t find an interpretation that won’t itself need an interpretation. That’s why at some point we need community practices.

10 thoughts on “Beware the DNR order

  1. This data is hard to interpret, primarily because most states have more than one kind of DNR order. For example, in the state of Ohio, there are “DNR-CC”, “DNR-CCA”, and “DNI” orders, as well as in some hospitals “DNR specified”. Since the post doesn’t make any distinctions between the kinds of orders, I worry that their questions and respondents could very well be confounding the different types.

    For example, a “DNR-CC” (or DNR comfort care) order is a medical order written by a physician, which orders the patient to receive comfort care only. This order would be entirely consistent with only administering limited treatments, and with (i.e.) not sending patients to the ICU – in fact, that is the purpose of this order. A DNR-CCA implies “comfort care upon arrest” (i.e. once a patient experiences cardiopulmonary arrest, after that point the only treatments which should be administered are those aimed at comfort) – and so again would be consistent with much of what the blog post summarizes.

    Given the variety of different types of orders, and their different meanings in different localities, I question the value of the kind of reporting in the link you shared. One thing is definitely clear, though: both caregivers and patients need to be better educated about the use and meaning of DNRs. Many medical schools are now making a concerted push to integrate ethics training and training about precisely these issues within their general medical curricula. Education outreach to patients is, sadly, lagging behind.

  2. This is an interesting post, thanks for sharing it. I talked about it with my partner last night (she is an MD resident in OB/Gyn), and here are some scattered thoughts about this post:

    We thought the framing was weird. The conclusions of the post are great. We need a better system of determining what treatments patients are wishing to get. In other words, we need more living wills and advanced directives. So, for example, Georgia has a Directive for Health Care, that covers a wide range of medical interventions that work as a checklist, and is standardized throughout the state. What is weird is framing this as fundamentally a problem with DNRs, which as Danielle points out, which are not standardized across states, and often not across hospitals. One could read (misread?) the post as primarily encouraging us to avoid DNRs as the main point, and increasing information about medical intervention as a minor point. The problem with DNRs is that they contain some information for medical treatment, but often not sufficient data, and this means that health care professionals engage in further interpretative practices. For example, take pediatric study above. A pediatric DNR is already a pretty strange thing. While I am not saying those health care practitioners are acting appropriately, I would be surprised if some interpretation doesn’t happen. So, basically, I agree with the conclusions of the article. I am bothered by the framing.

  3. Scu, thanks for your comment, which I expect will help readers. I agree that I could have put it better!

    I think the site from which I got the info is leaning against using DNR’s when they are the only thing you have to decide on. In fact, if you have to decide on a DNR and there isn’t surrounding material explaining details and/or allowing you to specify them, then it isn’t clear you should agree to it. You are in effect signing something which is associated with quite an array of varying practices, where your basic health and even life can be affected.

    I’ve had to deal with the question of DNR’s a couple of times where further info was absent. Fortunately, my decision wasn’t final. I did come to think that at least the hospital I was once dealing with didn’t think much should be done to help an 88 year old live much longer. That was very shocking.

  4. What about the opposite side of the coin?
    I would prefer to be allowed to die if I am likely to end up with an IQ in the retarded range. As an Advance Directive this would likely not be legal.

  5. Anne, sorry, I wasn’t trying to criticize your framing. I was trying to say I found the framing of the linked to site problematic. But I want to further clarify. I think it is problematic from the standpoint of policy advocacy or medical ethical advocacy. However, from the standpoint of determining what to do when you are a care giver, or making decisions about your own care (which is the way you framed the article, and something I should have paid better attention to), the question is clearly about the DNR itself when there is no other alternative. We clearly want doctors making as few interpretive decisions about care as possible (especially when so many of them are predisposed to thinking elder patients might want even less medical interventions).
    Sadly, pushing for better laws about advance directives seems unlikely in many states these days. GA’s is particularly good, but it was also passed in 2007, long before the death panels nonsense. I cannot see a law like that passing these days there.

    Daniel, I don’t understand how you think an advance directive would be undermine your ability to get a DNR?

  6. My concern has to do with whether DNR orders can be implemented in persons with no prior medical history; the wording is usually along the lines of “…in the event there is no reasonable expectation of recovery….” What if I am in an automobile accident, suffer traumatic brain injury that nonetheless will respond to treatment, leaving me in a state way above the level of a persistent vegetative state or coma, ie, with a reasonable expectation of recovery? What if I simply would rather not wake up to find myself facing years of rehabilitation with even mild cognitive dysfunction? Will a physician be legally able to allow me to die if I made this wish clear or is abiding my my wishes agreeing to my suicide?

  7. Daniel, I’m not fully sure. If your question is if you are allowed to refuse medical care that would cause your death, I am pretty sure that is legal (for the most part, obviously there have been issues with politicians who want to treat women’s bodies as incubators, etc) in America to deny treatment. Which means an advance directive would most likely be honored.

    Anne, thanks for the support! I’m a big fan of you, and everyone here at Feminist Philosophers.

  8. Daniel, this will vary by state. Your best bet is to draft a very explicit, specific advanced directive and (although not legally required in any state that I’m aware of – most allow simply two witnesses) have it witnessed by an attorney or notary public. The less room you leave for doubt with regard to your intentions and desires, the more likely that your wishes will be respected. (For context: I have seen advanced directives upwards of 20 pages long in Texas).

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