Do not awaken ( DNR ), also known as no codes or allow natural death , is a good written legal order in hospitals or in legal forms to withstand cardiopulmonary resuscitation (CPR) or support for advanced heart life (ACLS), in relation to the patient's wishes if their heart stops or they stop breathing. DNR requests are usually made by patients or health care workers from lawyers and allow the medical team to care for them to honor their wishes. In the health care community, allow natural death (AND) is a term that quickly gets help because it focuses on what is being done, not what is being avoided. Some criticized the term "unreasonable" because of the implications of important information being held, while research shows that only about 5% of patients require CPR outside the hospital and only 15% of patients need CPR while in hospitals survive. Elderly patients, living in nursing homes, have many medical problems, or who have advanced cancers, are less likely to survive.
DNR does not affect any treatment other than those requiring intubation or CPR. Patients who are DNR may continue to receive chemotherapy, antibiotics, dialysis, or other appropriate treatments.
Video Do not resuscitate
Terminology
DNR and Do not Resuscitation is a generic term in the United States, Canada, New Zealand and the United Kingdom. This can be clarified in some areas with the addition of DNI (Do Not Intubate), although in some hospitals DNR it will imply no intubation. Clinically, most people who need resuscitation will need intubation, making DNI alone a problem. Hospitals sometimes use the no code expression, which refers to the jargon term code , short for Code Blue , the hospital resuscitation team warning.
Several areas in the United States and Great Britain enter the letter A, as in DNAR , to clarify "Do Not Try Resuscitation." This change is not to be considered by the patient or the family that the resuscitation effort will be successful. Since the DNR term implies the omission of action, and therefore "surrender", some people suggest that these commands be affirmed Allow Natural Death . New Zealand and Australia, and some hospitals in the UK, using the terms NFR or Not For Resuscitation . Usually this abbreviation is not interspersed, e.g. DNR instead of D.NR.
The resuscitation order, or lack thereof, may also be referred to in the United States as part of the Doctor's Command for Patient Sustaining Treatment (POLST) or the Health Care Order Command for the Protection of Life (MOLST), usually made with input from the immediate family when the patient or client is unable to communicate their wishes.
The other synonym term is " not awake " ( NTBR ).
Until recently in the UK, usually wrote "No to 222" or in conversation, "Not for two alone." This is implicitly a DNR hospital order, where 222 (or similar) are hospital telephone numbers for emergency resuscitation or accident teams.
Maps Do not resuscitate
Landing and survival
The face and live will are documents written by the individual himself, thus expressing his desire to care, if they are no longer able to speak for themselves. Instead, it is a physician or hospital staff member who writes "DNR doctors' orders", based on the desires previously expressed by the individual in his direction or will of life. Similarly, at a time when the individual can not express his wishes, but has previously used the advance instructions to appoint an agent, the doctor may write like "DNR doctors' orders" at the request of the individual agent. These situations are clearly mentioned in the "sample" DNR order presented on this page.
It should be emphasized that, in the United States, face-to-face or volition life is not sufficient to ensure patients are treated under the DNR protocol, even if it is their intention, as there is no pre-directed or legally binding document of interest.
Ethics
The DNR order in certain situations has been subject to ethical debate. In many institutions it is customary for patients to undergo surgery to have their DNRs removed automatically. Although the reasons for this may be valid, since the results of CPR in the operating room are substantially better than the general survival outcomes after CPR, the impact on patient autonomy has been debated. It is recommended that facilities involve patients or their decision-makers in a 're-review by DNR order' rather than automatically making forced decisions.
There is much evidence of racial bias in DNR adoption. A 2014 study of end-stage cancer patients found that non-Latin white patients were significantly more likely to have DNR orders (45%) than black patients (25%) and Latino (20%). The correlation between preference to care extends life and the likelihood of improved advance care planning is consistent across ethnic groups.
The ethical dilemma occurs when a patient with DNR attempts suicide and the necessary treatment involves ventilation or CPR. In these cases it has been argued that the principle of generosity takes precedence over patient autonomy and DNR can be revoked by doctors. Another dilemma occurs when medical errors occur in patients with DNR. If a reversible error only with CPR or ventilation there is no consensus if resuscitation should be done or not.
There are also ethical concerns about how patients reach decisions to make themselves DNRs. One study found that when asked in more detail, many DNR patients actually wanted excluded interventions depending on the scenario. Most would prefer a life saving intubation in an angioedema scenario that usually goes away within a few days. One fifth of DNR patients want resuscitation for cardiac arrest but for treatment withdrawn after a week. It is possible that the provider has a "leading conversation" with the patient or mistakenly leaves important information when discussing DNR. One study reported that doctors repeatedly provided high-intensity care to patients while deciding that they would themselves be DNRs in similar circumstances.
There is also an ethical issue of interruption of cardioverter defibrillator implants (ICD) in DNR patients in cases of medical futility. A large survey of Electrophysiology practitioners, cardiac pacemaker planters and ICDs noted that practitioners felt that disabling ICDs did not differ ethically from holding CPR so that it was consistent with DNR. Most feel that disabling pacemakers is a separate issue and can not be widely supported ethically. Pacemakers are perceived as unique devices, or ethically taking on the role of "keeping the patient alive" like dialysis.
Usage by country
DNR documents are widespread in some countries and are not available in other countries. In countries where DNR is not available the decision to end resuscitation is made solely by the physician.
Middle East
DNR is not recognized by Jordan. Doctors try to awaken all patients regardless of individual or family desires. The UAE has laws that force health care staff to awaken the patient even if the patient has a DNR or does not want to live. There is a penalty for violating the law. In Saudi Arabia patients can not legally sign the DNR, but DNR is accepted on the orders of the primary physician in the case of a severely ill patient. In Israel, it is possible to sign the DNR form as long as the patient is dying and aware of their actions.
United Kingdom
England and Wales
In England and Wales, CPR is considered in the event of a heart attack unless resuscitation is not done. If they have the capacity as defined in the 2005 Mental Capacity Act, patients may resist resuscitation, but any discussion does not refer to approval for resuscitation and should instead be an explanation. Patients can also determine their wishes and/or submit their decision-making to proxies using advance instructions, often referred to as 'Living Wills'. Patients and relatives can not ask for treatment (including CPR) that doctors say is futile and in this situation, it is their doctor's duty to act in their 'best interests', whether it means continuing or stopping treatment, using their clinical judgment. If they lack relatives, they are often asked to respect their opinions.
Scotland
In Scotland, the terminology used is "Do not Try Heart Heart Resuscitation" or "DNACPR". There is one policy used in all the Scottish NHS. The legal position is similar to that in England and Wales, in CPR being seen as a treatment and, although there is a general presumption that CPR will be performed in cases of heart attack, this is not the case when seen by treating doctors to be useless. Patients and families can not demand CPR to be done if it is felt in vain (as well as medical care) and DNACPR can be issued despite disagreements, although it is a good practice to involve all parties in the discussion.
United States
In the United States, this documentation is very complicated because each country accepts different forms, and the initial directives and will of life can not be accepted by the EMS as legally valid. If a patient has a life-span that determines the patient's request from the DNR but does not have a properly state-sponsored form signed by the doctor, the EMS may attempt resuscitation.
DNR decisions by patients were first proposed in 1976 in In re Quinlan. The New Jersey Supreme Court upheld the rights of Karen Ann Quinlan's parents to order her dismissal from artificial ventilation. In 1991 Congress passed the Patient Determination Act which mandates hospitals to respect one's decisions in their health care. The current forty-nine states allow the nearest relative to make medical decisions of relatives who can not afford, except in Missouri. Missouri has Statute Living Will which requires two witnesses for each signed follow-up instruction resulting in DNR/DNI status code in the hospital.
In the United States, cardiopulmonary resuscitation (CPR) and advanced heart life support (ACLS) will not be performed if there is a valid "DNR" written order. Many countries do not recognize life will or health care guarantees in pre-hospital settings and pre-hospital personnel in areas that may be required to initiate resuscitation measures unless country-specific forms are properly filled and administered by physicians.
Canada
Do not awaken orders similar to those used in the United States. In 1995, the Canadian Medical Association, the Canadian Hospital Association, the Canadian Nursing Association, and the Catholic Health Association of Canada worked with the Canadian Bar Association to clarify and set up a guideline Joint Statement on Resusitative Interventions to be used to determine when and how DNR commands are assigned. The DNR order should be discussed by the physician with a significant patient or patient agent or other patient. Unilateral DNR by medical professionals may only be used if the patient is in a vegetative state.
Australia
In Australia, Do Not Resuscitate orders are covered by state-by-country policy laws.
In Victoria, the denial of the Medical Care Certificate is a legal way of refusing medical treatment from current medical conditions. This does not apply to palliative care (reasonable painkillers, food and drink). The Advanced Care Instructions legally define the medical care that a person may choose to receive (or not accept) under any given circumstances. This can be used to resist resuscitation, thus avoiding unnecessary suffering.
In NSW, the Resuscitation Plan is a medically authorized order to use or withstand the acts of resuscitation, and which document other aspects of the relevant care at the end of life. The plan applies only to physician patients who are members of the NSW Health staff. The plan allows for rejection of any maintenance that preserves life, refusal in advance for future inability, and the decision to move to pure palliative care.
Italy
DNR is not recognized by Italy. Doctors should try to awaken all patients regardless of individual or family desires. Italian law forces health care staff to awaken patients even if the patient has a DNR or does not want to live. There are prison sentences (6 to 15 years) for this unlawful health care staff, such as "omicidio del consenziente" - Links in Italian. Therefore in Italy, the signed DNR has no legal value.
See also
References
External links
- Do not Order Resuscitation Published by the US National Medical Library
- Decisions Related to Heart Heart Resuscitation Published by Resuscitation Council (UK)
Source of the article : Wikipedia
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