Ethics

Orders Not to Attempt Resuscitation (DNAR)

Code of Medical Ethics Opinion 5.4

The ethical obligation to respect patient autonomy and self-determination requires that the physician respect decisions to refuse care, even when such decisions will result in the patient’s death. Whether a patient declines or accepts medically appropriate resuscitative interventions, physicians should not permit their personal value judgments to obstruct implementation of the patient’s decision.

Orders not to attempt resuscitation (DNAR orders) direct the health care team to withhold resuscitative measures in accord with a patient’s wishes. DNAR orders can be appropriate for any patient medically at risk of cardiopulmonary arrest, regardless of the patient’s age or whether or not the patient is terminally ill. DNAR orders apply in any care setting, in or out of hospital, within the constraints of applicable law.

In the event a patient suffers a cardiopulmonary arrest when there is no DNAR order in the medical record, resuscitation should be attempted if it is medically appropriate. If it is found after the code is initiated that the patient would not have wanted resuscitation, the attending physician should order that resuscitative efforts be stopped.

Physicians should address the potential need for resuscitation early in the patient’s course of care, while the patient has decision-making capacity, and should encourage the patient to include his or her chosen surrogate in the conversation. Before entering a DNAR order in the medical record, the physician should:

(a) Candidly describe the procedures involved in resuscitation, the likelihood of medical benefit in the patient’s clinical circumstances, and the likelihood of achieving the patient’s desired goals for care or quality of life to address any misconceptions the patient may have about probable outcomes of resuscitation.

(b) Ascertain the patient’s wishes with respect to resuscitation—directly from the patient when the individual has decision-making capacity, or from the surrogate when the patient lacks capacity. If the patient has an advance directive, the physician should review the directive with the patient and confirm that the preferences set out in the directive about resuscitation are current and valid. The DNAR order should be tailored to reflect the particular patient’s preferences and clinical circumstances.

(c) Reinforce with the patient, loved ones, and the health care team that DNAR orders apply only to resuscitative interventions as they relate to the patient’s goals for care. Other medically appropriate interventions, such as antibiotics, dialysis, or appropriate symptom management will be provided or withheld in accordance with the patient’s wishes.

(d) Revisit and revise decisions about resuscitation—with appropriate documentation in the medical record—as the patient’s clinical circumstances change. Confirm whether the patient wants the DNAR order to remain in effect when obtaining consent for surgical or other interventions that carry a known risk for cardiopulmonary arrest and adhere to those wishes.

(e) Document in the medical record the patient’s clinical status, prognosis, current decision-making capacity, and preferences with respect to resuscitation, as well as the physician’s medical judgment about the appropriateness of resuscitation.

When the patient cannot express preferences regarding resuscitation or does not have decision-making capacity and has not previously indicated his or her preferences, the physician has an ethical responsibility to:

(f) Candidly and compassionately discuss these issues with the patient’s authorized surrogate and document the surrogate’s decision in the medical record.

(g) Revisit with the surrogate decisions about resuscitation as the patient’s clinical circumstances change, revising the decision as needed and updating the medical record accordingly.

(h) Seek consultation with an ethics committee or other appropriate institutional resource if disagreement about a DNAR order that cannot be resolved at the bedside.

When the patient’s preferences cannot be determined and the individual has no surrogate, the physician should consult with an ethics committee or other appropriate institutional resource before entering an order not to attempt resuscitation.

AMA Principles of Medical Ethics: I, IV, VIII

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Code of Medical Ethics: Caring for Patients at the End of Life

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