- Understand the differences between a do-not-resuscitate order, a living will and a power of attorney
- Understand treatment limitations of a DNR order
- Learn treatment options available for hospice and palliative care patients
- Discuss care for the body following death
Click here to access a 20-question review test for your training purposes.
Med-2 arrives at a skilled nursing facility at 2330 for a patient short of breath. The crew is greeted by a nurse, who directs them to the patient's room in the assisted-living side of the facility. The 65-year- old female moved in this past week after deciding she could no longer live independently. The nurse explains that the patient's shortness of breath has been worsening for the past six hours and has been treated with oxygen. She did not call 9-1-1 earlier because the patient has signed a do-not-resuscitate order; however, the patient's daughter arrived a little while ago and immediately requested an ambulance.
When the crew walks in, they see a well-dressed 65-year-old female on the edge of her bed, leaning forward in a tripod position, with a nasal cannula in place. Crackles can be heard from across the room, and the patient's lips look dusky. Her daughter says her mother has some heart trouble, but is otherwise healthy.
As the crew open their bags and turn on a monitor, the nurse says, "You cannot do all that. She is a DNR." Is the nurse right? Does the DNR prevent the crew from intervening? What can they do for a patient with a DNR? Are there limitations?
Following the development of CPR in the 1960s, all patients who experienced cardiac arrest received CPR. As the science around CPR progressed, ethicists challenged the ethical and moral necessity of prolonging the pain and suffering of terminally ill patients. This led to development of do-not-resuscitate orders, which first appeared in the mid-1970s.1 Following the pressure of ethicists, the American Medical Association (AMA) stated that CPR was not indicated in certain situations, specifically in cases of illness where death is an expected result.
Always contentious, resuscitation as a medical term means the procedures that attempt to restore cardiac and pulmonary function in an individual who has experienced cardiac or pulmonary arrest. CPR is the most commonly used term for resuscitation. When a patient has a do-not-resuscitate order, that order speaks specifically to performance of CPR. Traditionally, only patients with terminal illness, such as metastatic cancer, could obtain a DNR.
True to its word, a DNR order does not impact any medical care, assessment, diagnostic testing or intervention before a patient experiences cardiopulmonary arrest. As medicine has evolved, however, groups of patients have been identified who are nearing or at the end of life for whom the treatment focus becomes creating a comfortable end of life, rather than life preservation.2
The World Health Organization has defined palliative care as: "the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families."3
Today, hundreds of thousands of people have DNR orders, and most of them live independently and work and interact daily with society. These patients may become extremely sick from other causes, and it is important to remember they still have a large variety of treatment options available.2 Further, roughly a half-million U.S. patients are receiving hospice and palliative care benefits through Medicare and Medicaid.3
Sixty percent of Americans die at home, yet as few as 35% actually want to die there.3 As a result, 9-1-1 is often activated at some point in the dying process, even when patients have some sort of advance directive or are in palliative care. When interacting with these patients, it is important to know what treatments are available and what to avoid.