DNR Orders

How DNR Orders Guide End-of-Life Care Decisions

Do Not Resuscitate (DNR) orders are physician-directed medical orders that instruct healthcare providers not to attempt cardiopulmonary resuscitation (CPR) if a patient’s heart stops beating or they stop breathing. In hospice and palliative care, DNR orders reflect the patient’s right to refuse life-sustaining treatment and align care with goals of comfort, dignity, and quality of life.^[1]

DNR orders are a cornerstone of advance care planning and appear frequently on certification exams (e.g., CNA, CEN, FNP, Hospice Nursing). Clinically, understanding DNR orders ensures you can advocate for patient wishes, avoid unwanted resuscitation, and communicate effectively with families and interdisciplinary teams.^[2]

Essential Terminology and Documents for Resuscitation Decisions

• DNR (Do Not Resuscitate) – A medical order that prevents the initiation of CPR. It does not mean “do not treat.” All other comfort and medical interventions (e.g., oxygen, pain management, antibiotics) are continued unless otherwise specified.^[1]
• AND (Allow Natural Death) – A more patient-centered term for DNR that emphasizes allowing death to occur naturally without aggressive interventions. Used interchangeably with DNR in many hospice settings.^[3]
• Advance Directive – A legal document (e.g., living will, durable power of attorney for healthcare) that records a patient’s preferences for medical treatment, including resuscitation, if they become unable to communicate.^[2]a>
• POLST (Physician Orders for Life-Sustaining Treatment) – A portable medical order form that translates patient preferences into actionable medical orders, including DNR/DNI choices. It is more specific than an advance directive and is recognized across care settings.^[4]
• Code Status – A term used in hospitals to indicate whether a patient wishes to be resuscitated (full code) or not (DNR/DNI).
• Surrogate Decision-Maker – An individual (family member or legal guardian) authorized to make healthcare decisions on behalf of an incapacitated patient. The surrogate must base decisions on the patient’s known wishes or best interests.^[2]

Establishing DNR Orders and Differentiating from DNI

How DNR Orders Are Established

1. Patient Assessment – A healthcare provider (physician, NP, PA) assesses the patient’s medical condition, prognosis, and understanding of resuscitation outcomes.^[1]
2. Informed Discussion – The provider, patient, and/or surrogate discuss the benefits and burdens of CPR, the patient’s goals of care, and alternatives (e.g., comfort measures only). Communication must be clear, free of coercion, and documented.^[5]
3. Documentation – The order is written and signed by an authorized prescriber. In hospitals, it is entered into the electronic medical record. Out-of-hospital DNR orders (e.g., for home hospice) may be printed on a specific form and kept visible.^[4]
4. Communication – The order is communicated to all care team members, including nursing staff, respiratory therapy, and emergency responders (via EMS if applicable).^[6]
5. Review and Revision – DNR orders are reviewed periodically (e.g., with changes in condition, transfer between settings) and can be revoked at any time by the patient or surrogate.^[1]

Key Distinction: DNR vs. DNI

• DNR – Applies only to cardiac arrest (no chest compressions, defibrillation, advanced airway). Does not apply to other emergencies like choking or anaphylaxis; basic life support measures (e.g., Heimlich, epinephrine) may still be given per separate orders.^[1]
• DNI (Do Not Intubate) – Prohibits endotracheal intubation but permits other forms of respiratory support (e.g., BiPAP, oxygen) if the patient wishes. DNR and DNI orders are often combined but can be written separately.^[6]

Visual and Documentation Indicators of a DNR Order

DNR orders themselves produce no clinical signs, but they are reflected in the patient’s environment:

• Written DNR order placed prominently in the chart or bedside (e.g., in home hospice on the refrigerator or next to the patient).
• Code status documentation in the electronic medical record (color-coded alert, “DNR” flag).
• Patient wears a medical alert bracelet indicating DNR (in some regions for out-of-hospital orders).^[4]
• Presence of a POLST or MOLST form signed by the physician.

Verifying DNR Orders and Applying Ethical Assessment Models

How to Verify a DNR Order

1. Confirm the order is written – The order must be signed and dated. Verbal orders are often not accepted except in specific emergencies and must be co-signed within 24 hours.^[1]
2. Check the context – Ensure the order applies to the current setting (some DNR orders are setting-specific, e.g., hospital vs. home).
3. Identify the patient – Match the order to the correct patient using two identifiers (name, DOB).
4. Review for restrictions – Some DNR orders have modifications (e.g., “allow defibrillation but not intubation”) that require clarification.^[6]
5. Evaluate capacity – Ensure the patient or surrogate was competent and informed at the time of order placement.^[5]

Ethical Assessment Tools

• Four-Box Model – Used to analyze ethical dilemmas: medical indications, patient preferences, quality of life, contextual features. For DNR, patient preferences and medical futility are central.^[7]
• Capacity Assessment – If a patient’s decision-making capacity is doubted, a formal assessment (e.g., using the Mini-Mental State Exam or the Aid to Capacity Evaluation) may be performed.

Care Strategies When a DNR Order Is in Place

• Comfort measures only (CMO) – In hospice, DNR often goes hand-in-hand with a CMO plan: aggressive symptom management (pain, dyspnea, anxiety) without any life-prolonging treatments. Nursing actions include administering medications, repositioning, providing emotional support.^[3]
• Continuing non-resuscitative care – DNR does not stop treatments like antibiotics, IV fluids, dialysis, or palliative radiation. Each must be discussed separately.^[1]
• Family support – Educate family about what DNR means (and does not mean). Answer questions about “giving up” or “starving” – clarify that comfort and dignity are the priority.^[2]
• Temporary suspension of DNR – In rare situations (e.g., surgery under anesthesia), DNR may be temporarily suspended per facility policy and patient/surrogate agreement, with clear documentation of the time frame.^[6]

Common Risks, Legal Issues, and EMS Challenges with DNR Orders

• Misinterpretation – A DNR order is sometimes mistakenly thought to mean “do not treat.” This can lead to neglect of reversible conditions (e.g., sepsis) that could be treated to improve comfort. Always clarify with the team.
• Conflict with family – Family members may object to DNR out of guilt or misunderstanding. Use ethics consultation if needed.^[7]
• Legal risks – Failure to follow a valid DNR order constitutes battery (unwanted resuscitation). Conversely, following an invalid or expired DNR order could lead to wrongful death claims. Always verify the order.
• Emergency medical services (EMS) challenges – Out-of-hospital DNR orders must be instantly identifiable. If EMS cannot find the order, they are obligated to resuscitate. Encourage patients to keep DNR forms visible (e.g., on the refrigerator).^[4]
• Transfer issues – When a patient is transferred (hospital to hospice, or vice versa), DNR orders may not automatically transfer. The receiving provider must re-evaluate and issue a new order if appropriate.^[1]

Crucial Distinctions and Exam-Focused Reminders for DNR Orders

• Memorize the difference – DNR applies only to cardiac arrest; DNI applies to respiratory failure. Both are separate orders, though often combined.
• Know the documentation requirements – A DNR order must be in writing, signed, dated, reviewed periodically, and clearly communicated. Verbal orders are typically not accepted for DNR in most settings.
• Patient autonomy is key – The ethical principle of autonomy underpins DNR. Remember: beneficence (doing good) sometimes requires honoring a DNR to prevent suffering.
• Common exam question: “A patient with a DNR order develops respiratory distress. What should the nurse do?” Answer: Provide oxygen and comfort measures, but do not intubate. The DNR/DNI must be respected.
• Memory aid: “DNR = No chest compressions; DNI = No tube down the throat.”
• Distinguish from advance directive: A DNR is a medical order; an advance directive is a legal document. An advance directive is not immediately actionable without a physician’s order.
• Reversible conditions: DNR does not apply to choking, drowning, or trauma scenarios where a reversible cause is present and the patient would want treatment. Clarify with the team.

References & Sources

1. National Hospice and Palliative Care Organization (NHPCO). Ethics and Advance Care Planning: DNR Orders. 2023. https://www.nhpco.org/ethics-advance-care-planning/
2. Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier. Chapter 8: Ethical and Legal Issues. ISBN: 9780323328524.
3. Hospice and Palliative Nurses Association (HPNA). Position Statement: Allow Natural Death (AND) vs. Do Not Resuscitate (DNR). 2021. https://www.hpna.org/Position-Statements
4. POLST (Physician Orders for Life-Sustaining Treatment) National Paradigm. POLST: How It Works. 2023. https://polst.org/
5. American Medical Association (AMA). Code of Medical Ethics Opinion 5.1: Advance Care Planning. 2016. https://www.ama-assn.org/delivering-care/ethics/advance-care-planning
6. American Heart Association. 2020 AHA Guidelines for CPR and ECC: Ethical Issues. Part 3: Ethics of Resuscitation. https://doi.org/10.1161/CIR.0000000000000912
7. Jonsen, A. R., Siegler, M., & Winslade, W. J. (2018). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (8th ed.). McGraw-Hill Education. Chapter 4: The Four-Box Model. ISBN: 9781260457544.