A DNR order is a medical order issued by a physician or other authorized practitioner that directs healthcare providers not to administer CPR (Cardio Pulmonary Resuscitation) in the event of cardiac or respiratory arrest. A DNR order may be written in the absence of a living will or the conditions that would make a living will operative. A living will may contain a provision indicating that a patient does not desire CPR. However, if a patient’s preference to forgo CPR is expressed only in a living will, CPR will be withheld only when a physician has determined that the patient is not competent and has certified in writing that the patient has an end-stage medical condition or is permanently unconscious.1 Without such physician determination and certification or without a DNR order, the patient’s expressed preference for withholding CPR is not sufficient.2 In order for a patient’s preferences to be carried out, patients, families, and healthcare providers must understand the distinction between the circumstances under which a living will and a DNR order are applicable.
A DNR order is not subject to the preconditions imposed by the Living Will Act. A DNR order becomes operative only in the narrow context of cardiac or respiratory arrest regardless of the precipitating clinical event and does not preclude otherwise appropriate treatments or life-sustaining interventions.2,7 Misinterpretation of DNR orders was demonstrated by a survey conducted in an outpatient cancer center, which showed that only 34% of the patients correctly understood the meaning of a DNR order; 66% of the patients did not realize that a DNR order would result in not being resuscitated even if the cause of the cardiac or respiratory arrest was potentially reversible.8
In June of 2002 Pennsylvania enacted the Do-Not-Resuscitate Act (DNR Act) (P.L. 409, No. 59) (20 Pa.C.S. §§ 54A01-54A13). The DNR Act empowered a terminally ill person or the person’s surrogate to secure an out-of-hospital do-not-resuscitate order and, at the person’s option or the option of an authorized representative, an out-of-hospital DNR bracelet or necklace. These items direct emergency medical services (EMS) personnel in the out-of-hospital setting not to provide the person for whom they are issued with cardiopulmonary resuscitation in the event of the person’s cardiac or respiratory arrest. The DNR Act also specified the circumstances under which an appropriate representative of a person who issued a declaration under the Advance Declaration for Health Care Act (former Living Will Act) would be able to secure an out-of-hospital DNR order, bracelet or necklace for the person if the person became permanently unconscious. These provisions, supplemented by Department of Health regulations (28 Pa. Code §§ 1051.1-1051.101), went into effect March 1, 2003, and were amended February 7, 2004.
Specifically, an out-of-hospital DNR order is a written order that is issued by a person’s attending physician that directs EMS providers to withhold CPR from the person in the event of that person’s cardiac or respiratory arrest. Thus, if an ambulance is called to attend to a person for whom an out-of-hospital DNR order has been issued and the ambulance crew observes the out-of-hospital DNR order with original signatures with the person, or observes that the person is wearing an out-of-hospital DNR bracelet or necklace, the ambulance crew will not attempt CPR unless it is appropriately communicated to a member of the crew that the out-of-hospital DNR order has been revoked.
1. Cardio-Pulmonary Resuscitation (CPR): refers to the medical procedures used to restart a person’s heart and breathing when the person suffers cardiac or respiratory arrest. CPR may involve simple efforts such as mouth-to-mouth resuscitation and external chest compression. Advanced CPR may involve insertion of a tube to open the person’s airway or to assist breathing, injection of medications, or providing an electrical shock (defibrillation) to resuscitate the heart.
2. End-Stage Medical Condition: An “end-stage medical condition” is an incurable and irreversible medical condition in an advanced state caused by injury, disease, or physical illness that will, in the opinion of the attending physician, to a reasonable degree of medical certainty, result in death, despite the introduction or continuation of medical treatment. If a patient having an end-stage medical condition serves as the reason for which an out-of-hospital DNR order is sought for that patient, the attending physician must make the determination that the patient has an end-stage medical condition before the physician may issue an out-of-hospital DNR order for the patient. All persons who are in a terminal condition have an end-stage medical condition.
3. Permanently Unconscious: “Permanently unconscious” is a medical condition that has been diagnosed in accordance with currently accepted medical standards and with reasonable medical certainty as total and irreversible loss of consciousness and capacity for interaction with the environment. The term includes, without limitation, a persistent vegetative state or irreversible coma. If a patient being permanently unconscious serves as the reason for which an out-of-hospital DNR order is sought for the patient, the attending physician must make the determination that the patient is permanently unconscious and the patient must have previously executed a living will which provides that no CPR be administered in the event of the person’s cardiac or respiratory arrest if the person becomes permanently unconscious, or authorizes a surrogate or other authorized representative of the person to make that decision under those circumstances.
4. Emergency Medical Services (EMS) Provider: EMS providers are individuals licensed, certified, recognized, or otherwise authorized under the Emergency Medical Services Act (35 P.S. §§ 6921-6934) to provide medical care on an emergency, out-of-hospital basis. They are most frequently associated with ambulance services. EMS personnel who administer emergency treatment include EMTs (emergency medical technicians), EMT-paramedics (paramedics), prehospital registered nurses, ambulance attendants, first responders and health professional physicians. EMS providers also include individuals given good Samaritan civil immunity protection under Pennsylvania law (42 Pa.C.S. § 8331.2) when using an automated external defibrillator. Physicians who provide medical command to EMS personnel must also honor an out-of-hospital DNR order when appraised of it by EMS personnel.
5. Attending Physician: An attending physician is a physician who has primary responsibility for the treatment and care of the person. More than one physician may have primary responsibility for the medical care and treatment of a person. A physician who is requested to issue an out-of-hospital DNR order for a person needs to make a good faith judgment as to whether the physician is an attending physician of the person based upon the medical care the physician provides to the person. If the physician determines that the circumstances of the physician-patient relationship do not enable the physician to determine whether he or she qualifies as the patient’s attending physician, the physician will attempt to supplement that knowledge with information the physician secures after making reasonable inquiries of the person or the person’s surrogate or other authorized representative regarding the medical care the person is receiving from other physicians.
6. Surrogate: For purposes of the repealed DNR Act and the regulations that were adopted pursuant to that act, a surrogate is an individual who has, or individuals who collectively have, legal authority to request an out-of-hospital DNR order for another person or to revoke that order. Under the Act the term “surrogate” is limited to a health care agent or health care representative as those terms are defined in the Health Care Agents and Representatives Act (20 Pa.C.S. §§ 5451-5465). This does not include all persons who fall under the former definition of “surrogate.” However, the Act permits persons other than surrogates, by virtue of their special relationship to the person for whom an out-of hospital DNR order is sought, to also make a request for an out-of-hospital DNR order for that person. An example of such a person is a parent of a child who has an end-stage medical condition who is under 18 years of age and who is not emancipated, who has not graduated high school or been married, and who does not have a court-appointed guardian. Yet another example is a court-appointed guardian for an adult who has an end-stage medical condition and who the court concludes is unable to meet essential requirements for his or her physical health or safety because the person does not have the ability to receive and evaluate relevant information effectively or communicate relevant decisions. However, other than when a person is relying upon the definition of “surrogate” in the Act to qualify to ask for an out-of-hospital DNR order for another person, the focus should be on whether that person, by virtue of a special relationship to the person for whom the out-of-hospital DNR order is sought, has legal authority to request an out-of-hospital DNR order for that person. We encourage you to seek the advice of an attorney if you have a question regarding who can serve as a surrogate or other authorized representative for another person to request an out-of-hospital DNR order for that person.