Do Not Resuscitate Documents and Caring for the Elderly

Introduction

This article focuses on why, when, and how to create and maintain a Do Not Resuscitate (DNR) order. It is written specifically for the elderly who reside in nursing homes, assisted living communities or are receiving home care, as well as those who are caring for elderly individuals. However, the information contained herein is also relevant to the larger community concerned about making healthcare decisions.

 One Idea, Many Names - A Do Not Resuscitate is referred to by many names, and subtle variations exist between these concepts. However, be aware that the following names, more or less, refer to the same idea. 

-Allow Natural Death (AND)
-Comfort Care Order (CCO)
-Do Not Attempt Resuscitation (DNAR)
-Do Not Intubate (DNI) or Resuscitate
-No Code

-Medical Orders for Life-Sustaining Treatment (MOLST)
-Out-of-Hospital Do Not Resuscitate Order (OOHDNR)
-Physician Orders for Scope of Treatment (POST)
-Provider Order for Life Sustaining Treatment (POLST)
-Clinician Orders For Life Sustaining Treatment (COLST)
-End-of-Life Medical Orders (ELMO)

Description and Purpose

A Do Not Resuscitate is a document that informs medical professionals that they should not provide cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) to an individual if that individual stops breathing or if their heart stops. In common language, this is a document that essentially says "don't put me on life support". There are variations on this concept, such as Do Not Intubate.

In the context of the elderly who are receiving care, a DNR is more relevant to those living at home.  A DNR is largely intended for emergency response personnel who are unfamiliar with the individual.   It is likely that those who live in residential care will have communicated (or been asked) their wishes in advance by the caregivers around them.

DNR vs. Advance Healthcare Directive / Living Wills

A DNR is similar to an advance health care directive or a living will.  Some may argue that a DNR is, in fact, a type of advance health care directive.  However, there is a clear distinction in that a DNR is under the order of a physician while a health care directive or living will can simply be an expression of the individual's desire.  A DNR is a more formal, legal document and it is intended for emergency medical personnel. 

An DNR also tends to have a single, very distinct purpose: "Don't revive me".  While a living will might state the opposite:  "Do everything in your power to keep me alive".   This lack of ambiguity in a DNR makes it more likely that the individual's preferences will be followed.  

DNR vs. Healthcare Power of Attorney (POA)

Both DNRs and Healthcare POAs express what to do in the situation in which individuals cannot communicate for themselves. However, with a DNR their desires are communicated through a physician while with a Power of Attorney, the individual designates someone else to make healthcare decisions on their behalf. In reality, DNRs tend to be for immediate actions taken by emergency responders, while POAs tend to be for healthcare decisions made on a non-emergency basis.

 

Creating a DNR

Relevant Parties

Unfortunately the process for creating a Do Not Resuscitate differs in each state.  We have included state specific links below.  Generally speaking, one can download a template from their state's website, complete that form and have it signed by a physician.

There are surprisingly few required parties.  There is the individual for whom the DNR applies.  However, they are not required if they have a legal representative or have previously created a Healthcare Power of Attorney.  In most states a physician is required to authorize the document.  Some states require witnesses or notaries, but this is fairly unusual.  An attorney is not required.

Who Should Create a DNR

Unlike many other legal documents for the elderly which are relevant to a wide audience, a DNR is really only applicable to a small portion of the population.  As the default course of action is to resuscitate, it is only necessary for those who wish not to be resuscitated to create this legal document.

Storage / Placement of the DNR

A DNR's primary audience is emergency response personnel. Emergency responders are commonly unfamiliar with the individual, and hence, will have no knowledge of the document's existence. Therefore, it is crucial to place copies of the document in high profile locations in one's home to attract the attention of emergency responders.

Of course, many emergency responses occur outside of the home. Therefore, many persons choose to wear an item on their body that indicates that they have a DNR. Most common are necklaces or bracelets. Most emergency responders have been trained to look for these items.

 

Costs

In most states, there are no costs or fees associated with the creation of a DNR. Having said that, there are always exceptions. Some states may have a registration fee, but if they do, the fee should be relevantly minor, perhaps $25.

 

Download Your State's DNR Form

Each state has their own specific version of a Do Not Resuscitate.   Some of the links that follow go directly to a downloadable template and other links describe the legal process to create a DNR for a particular state, but do not offer templates.  Regardless, these links are a good place to begin the process.