DNAR Orders

Unlike other medical interventions, CPR is initiated without a physician's order, based on implied consent for emergency treatment. A physician's order is necessary to withhold CPR. Physicians must initiate a discussion about the use of CPR with all adults admitted for medical and surgical care or with their surrogates. Terminally ill patients may fear abandonment and pain more than death, so physicians should also reassure the patient and family that pain control and other aspects of medical care will continue even if resuscitation is withheld.

The attending physician should write the DNAR order in the patient's chart with a note explaining the rationale for the DNAR order and any other specific limitations of care. The limitation-of-treatment order should contain guidelines for specific emergency interventions that may arise (eg, use of pressor agents, blood products, or antibiotics). The scope of a DNAR order should be specific about which interventions are to be withheld. A DNAR order does not automatically preclude interventions such as administration of parenteral fluids, nutrition, oxygen, analgesia, sedation, antiarrhythmics, or vasopressors unless these are included in the order. Some patients may choose to accept defibrillation and chest compressions but not intubation and mechanical ventilation.

Oral DNAR orders are not acceptable. If the attending physician is not physically present, nursing staff may accept a DNAR order by telephone with the understanding that the physician will sign the order promptly. DNAR orders should be reviewed periodically, particularly if the patient's condition changes.

The attending physician should clarify both the DNAR order and plans for future care with nurses, consultants, house staff, and the patient or surrogate and offer an opportunity for discussion and resolution of conflicts. Basic nursing and comfort care (ie, oral hygiene, skin care, patient positioning, and measures to relieve pain and symptoms) must always be continued. DNAR orders carry no implications about other forms of treatment, and other aspects of the treatment plan should be documented separately and communicated to staff.

DNAR orders should be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate to determine their applicability in the operating suite and postoperative recovery room.

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