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Do Not Resuscitate (DNR) Orders

In Ohio there are several legally-recognized ways for you to give doctors and other health care providers instructions about the medical treatment you wish to receive (or do not wish to receive) -- before you actually need the care. You may have heard about "advance directives" such as "living wills" and "health care powers of attorney." Ohio law also recognizes another tool to help you and your physician do effective health care planning for the end of life. It is called a DNR order.

What does DNR mean?

DNR stands for "do not resuscitate." A person who does not wish to have cardiopulmonary resuscitation (CPR) performed may make this wish known through a doctor's order called a DNR order. A DNR order addresses the various methods used to revive people whose hearts have stopped functioning or who have stopped breathing. Examples of these treatments include chest compressions, electric heart shock, artificial breathing tubes, and special drugs.

Under its DNR Comfort Care Protocol, the Ohio Department of Health has established two standardized DNR order forms. When completed by a physician (or certified nurse practitioner or clinical nurse specialist, as appropriate), these standardized DNR orders allow patients to choose the extent of the treatment they wish to receive at the end of life. A patient with a "DNR Comfort Care-Arrest Order" will receive all the appropriate medical treatment, including resuscitation, until the patient has a cardiac or pulmonary arrest, at which point only comfort care will be provided. By requesting the broader "DNR Comfort Care Order," a patient may reject other life-sustaining measures such as drugs to correct abnormal heart rhythms. With this order, only comfort care would be provided at a point even before the heart or breathing stops. Your doctor can explain the differences in DNR orders.

Does everyone want CPR?

Although in some cases it does save lives, CPR (cardiopulmonary resuscitation) frequently is not successful or does not benefit those who receive it, especially for elderly people or those with serious medical conditions. Even if the person is revived, he or she can be left with painful injuries or in a very debilitated state. Resuscitation can involve such things as drugs, forcefully pressing on the chest, giving electric shocks to restart the heart or placing a tube down the nose or throat to provide artificial breathing. People with terminal illnesses or other serious health conditions may prefer to "die with dignity" instead of being resuscitated when the end comes. For more information about the pros and cons of CPR and whether it is right for you, talk with your doctor.

How do I make my wishes about CPR known? How do I get a DNR order?

If you do want to receive CPR when it is medically appropriate, you don't have to do anything. Emergency squads and other health care providers must provide CPR whenever medically appropriate. If you do not want CPR, you always have the right to refuse it (or any other medical treatment), but most likely you won't be able to state your wishes when an emergency happens. Therefore, if you do not want CPR, you should discuss your wishes with your doctor and ask your doctor to write a DNR order -- a medical order saying that CPR should not be given.

The doctor will explain the different ways the order can be written and may use one of the Ohio Department of Health's two standard DNR order forms. Your doctor is not required to use a standard form. However, an advantage to using a standard form is that it is easily recognized by paramedics and other health care workers.

Why has Ohio adopted a new law about DNR?

Because Ohio's 1991 Living Will Law focused on patients in hospitals and nursing homes, there was uncertainty about the circumstances under which an emergency health care worker could act on a DNR order and honor a person's wish not to have CPR. The purpose of the 1998 DNR Law is to help people communicate their wishes about resuscitation to medical personnel outside a hospital or nursing home setting. It allows emergency medical workers to honor patients' physician-written DNR orders even if they are at home rather than in the hospital when the heart or breathing stops. The 1998 DNR Law also protects emergency squads and other health care providers from liability if they follow their patients' DNR orders outside a hospital or nursing home setting.

How will the emergency squad or anyone else know I have a DNR order?

If you are a patient in a hospital or nursing home, the DNR order should be in your medical chart. You or your family also should notify the medical staff that you have such an order any time you are admitted to a facility or are transferred from one facility to another. If you are receiving care at home, you should tell your family and caregivers where to find your DNR order. You also may want to talk with your doctor about getting DNR identification such as a wallet card or bracelet that tells medical personnel you have a DNR order.

Can anyone else override my wishes about CPR?

No. You have the right to make your own decisions about your health care. If you are not able to express your wishes, other people such as your legal guardian, a person you named in a health care power of attorney, or a family member can speak for you. You should make sure these people know your desires about CPR. If your doctor writes a DNR order at your request, your family cannot override it.

What if I change my mind after my doctor writes a DNR order?

You always have the right to change your mind and request CPR. If you do change your mind, you should talk with your doctor right away about revoking your DNR order. You also should tell your family and caregivers about your decision, mark "cancelled" on the actual DNR order, and destroy any DNR wallet cards or other identification items you may have.

What is the difference between a living will and a DNR order?

Both living wills and DNR orders deal with end-of-life decisions, but they are different. You may complete a living will document yourself even when you are healthy. Your living will document specifies in advance the kind of medical treatment you would want if and when you have a terminal illness or are in a permanently unconscious state and are no longer able to state your own wishes.

By contrast, you do not write a DNR order for yourself. Instead, you make your wishes known to your physician, who writes a DNR order if and when your condition warrants it. The DNR order addresses your current state of health and the kind of medical treatment you and your physician decide is appropriate under current circumstances.

How does a person use a living will to obtain a DNR order?

Ohio has a standard Living Will Declaration form that is widely available. This standard form specifically directs your physician to write a DNR order for you if two doctors have agreed that you are either terminally ill or permanently unconscious. Your attorney and your doctor can help answer questions about the living will form, including the DNR issue.

How does a health care power of attorney differ from a living will? From a DNR order?

Another kind of advance directive available under Ohio law is called the health care power of attorney. This is a document that names another person (usually a spouse, child, or other relative) to make health care decisions for you whenever you are unable to do so yourself. These decisions could range from something as simple as whether to see a doctor to something as significant as whether to have surgery or to terminate treatment.

A living will, unlike a health care power of attorney, expresses your wishes directly to the health care provider and applies only if you are terminally ill or permanently unconscious.

A health care power of attorney is not a DNR order, although a health care power of attorney ordinarily would permit the person you appoint to agree to a DNR order for you, if you are unable to express your wishes at the time.

More information about advance directives is available in the publication, "What you should know about . . . Living Wills and Health Care Powers of Attorney," published by the Ohio State Bar Association.

Can I use a general power of attorney to address my health care wishes?

No. You may have given your general power of attorney to someone to manage your financial affairs while you were on vacation or in the hospital. This general type of power of attorney usually does not address health care issues and ends if you become disabled.

If you want a general power of attorney to continue, even if you become disabled, the document must state that it is a "durable" or continuing power of attorney. A health care power of attorney is a "durable" power; it continues even after you become disabled and appoints someone to carry out your health care wishes. Health care providers will more readily recognize your power of attorney if it is in a separate document expressly addressing health care matters.

How are DNR orders, living wills, and health care powers of attorney used?

A living will might be used to direct a physician to write a DNR order:

Jane decides she does not want CPR to be given to her. She obtains a living will form and fills it out properly. Later, Jane becomes debilitated and needs home health care, but she hasn't discussed resuscitation with her doctor and a specific DNR order has not been written.

One day, the visiting nurse arrives to find that Jane is not breathing. At this point, the nurse begins CPR, because a DNR order has not been written. If Jane is resuscitated and transferred to a hospital, but remains unconscious, her doctors may decide she is in a terminal condition. Jane's living will can serve as evidence that she does not want to be resuscitated in such a circumstance. Her doctor may write a DNR order so that, if Jane's heart stops beating again, she will not be resuscitated.

A health care power of attorney might be used to authorize a DNR order:

Bill decides that, under some circumstances, he would not want CPR to be given to him and informs his family of this decision. He obtains a health care power of attorney form and fills it out properly, appointing his wife to make health care decisions for him if he is unable to do so. Later, Bill is seriously injured in an accident and is moved to a hospital while he is unconscious. His doctors are made aware of the health care power of attorney, and Bill's wife informs them that Bill would not want CPR if his heart or lungs should stop functioning. The doctors write a DNR order, indicating on Bill's medical chart that he is not to be resuscitated. One day, his heart stops. Since Bill's doctor has written a DNR order, the health care workers do not resuscitate him.

A DNR order alone might be used as in the following example:

John is terminally ill and decides he does not want CPR to be given to him. He discusses his wishes with his doctor, and the doctor writes a DNR order for John on the Ohio Department of Health form, signs it, and gives it to John.

Later, John becomes debilitated and needs home health care. John informs his family of his DNR order and gives them a copy. One day, his daughter comes in and finds that John is not breathing. She becomes alarmed and calls 9-1-1. Because John's daughter shows the DNR order to the medic who arrives, the medic does not perform CPR, but does provide John with comfort care.

Where can I get further information? Can I draw up my own documents?

The Ohio State Bar Association, the Ohio State Medical Association, the Ohio Hospice & Palliative Care Organization, and the Ohio Hospital Association have jointly revised a standard Living Will Declaration form and a standard Health Care Power of Attorney form. These forms may be obtained from doctors, lawyers, hospitals, nursing homes, and others. You also may obtain a copy of these forms by mailing a request along with $3 to the Ohio Hospice & Palliative Care Organization, 1646 W. Lane Ave., Suite 2, Upper Arlington, Ohio, 43221, or visit that organization's Web site at .

You do not have to use the standard forms. For any document to be valid, however, it must meet certain requirements under Ohio law. If you wish, your lawyer can prepare a living will and/or health care power of attorney that is specifically tailored to your situation.

If you are interested in obtaining a DNR order, you will need to speak with your doctor, who can complete the appropriate forms for the order, and can tell you how to obtain a wallet card, bracelet or other DNR identification.

Reprinted courtesy of the Ohio State Bar Association

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