If you’ve been admitted to the hospital in the last few years (and are over 18 years of age), for any reason, it is required that the admitting physician ask you what you want your “code status” to be.  While most of us in health care are busy patting ourselves on the back for this great advance in honoring end of life wishes, what exactly does the question mean?  To most people unfamiliar with the medical system and end-of-life issues, this question is both fear provoking and difficult to answer.

I’ve watched countless patients be asked this question through the years, without counseling, without any more information than the simply phrased question:  “If your heart should stop beating what do you want done?”  or “What do you want your code status to be?”.  It increasingly baffles me how we can expect someone at such a vulnerable moment to make such an important decision without the necessary information to make a truly informed choice.   I continue in my practice and in my life, trying to help people answer these questions before this critical moment, when cooler heads prevail and information can be processed so a truly informed decision can be made.

So what does the question mean?  What is DNR?  What is DNI? What is a POLST?  What is a Living Will or a Durable Medical Power of Attorney? How do you learn about your choices and make them appropriately in accordance with your own values and your perception of quality of life?  It often seems that there are so many options out there that it becomes nearly impossible to sort through what you actually need and find what really works.   There’s way too much information here to cover in one post, so we’ll take it one piece of paperwork at a time.

DNR – Do Not Resuscitate

DNR is one type of Advanced Directive or a specific part of a larger Advanced Directive.  Declaration of DNR is often initiated in a physician signed copy of an Advanced Directive – I will cover the Advanced Directive more broadly in an upcoming post.    Advanced Directives and DNR paperwork vary by state.  Links to state specific forms can be found Here.

Though this is a term that most of the general population has become familiar with over the years, most people are unfamiliar with the ins & outs and the potential areas of difficulty around having your DNR wishes honored.

DNR Status means that you do not wish to have CPR (cardiopulmonary resuscitation) performed on you if your heart should stop beating.  DNR does not mean do not treat you in other circumstances.  DNR refers specifically to receiving CPR, though many people think it reaches more broadly.  If you are DNR you can still have surgery (though you should have a discussion with the surgeon and anesthesiologist as to your wishes if your heart stops in the OR).  You can still receive life saving treatments such as antibiotics, oxygen and blood pressure medications, even dialysis.  If your illness should progress however, to the point that your heart stops, no CPR will be attempted.

IF – the paperwork you have stating your wishes is accepted by the state you are currently in.
IF- you have the correct copy of that paperwork on you at the time of needing life sustaining treatment, or on file with EMS crews and your local hospital.
IF – your wishes are clearly stated in a way that cannot be ambiguous or misinterpreted.
IF – Immediate family or your durable medical power of attorney agree with the written wishes and do not seek to override your decision and request resuscitative efforts.

The IF’s stated above are part of what make communication key to this process.  You can have every signed legal document available, but if the people you love and trust don’t know your wishes, if they don’t have copies of the documents, then it is much more difficult for your voice to be heard if the moment comes that you cannot speak for yourself.

DNR works best if it is discussed with family and a named Durable Medical Power of Attorney.  Imagine that you have decided that you want to be DNR, you have worked with your physician to sign the proper forms and make proper arrangements, but you never discuss this with your legal next of kin (closest living relative) or the person you name to make decisions for you in the event of a medical emergency (durable medical power of attorney).    Something happens and you are unresponsive, your family doesn’t know what you would have wanted, their initial reaction is to do everything.  What will happen?  Most likely CPR will be initiated against your wishes.  Why?  Because rarely at the moment of crisis is there time to go seeking paperwork and Emergency Medical Workers are required to start resuscitative efforts immediately.

Due to varying state requirements for what constitutes a legal DNR order, alternative methods of “declaring” your status, such as bracelets and tattoos are not legally actionable.  (Besides, imagine if you married David Nelson Richards and decided one day to have his initials tattoo’d on your chest, imagine down the road that Emergency Medical Crews respond to a call where your heart has stopped and withhold CPR because of your DNR tattoo….oops!).

The only place that bracelets can be a valid identifier of code status is in the hospital.  Many hospitals have gone to a system where inpatients who have elected DNR status on admission and have a signed doctor’s order to verify it, are given a bracelet of a specific color or one saying DNR.  These are legally actionable by hospital staff, in the case your heart stops beating during this hospital admission, the bracelet will be honored.

Similar to DNR there is another part of the advanced directive that is becoming more and more “popular”.  This is called a DNI or Do Not Intubate.  In the case of respiratory distress, when your breathing efforts become too difficult to sustain without assistance and fail less invasive measures, unless otherwise stated, you will be intubated (have a breathing tube inserted into your lungs) and placed on a ventilator (a machine which forces air in and out of the lungs).

DNR and DNI are separate statuses which are often elected together but do not have to be.  If a person elects neither DNR or DNI then most likely, in cases of cardiac arrest (when your heart stops for any reason) you will be intubated and CPR will be performed until a heart beat returns or efforts are deemed futile and ceased.   For more information on the effectiveness of CPR please see my previous post by clicking here.

Regardless of your choices, as always I will repeat how vital it is to share them with those you love, help them to know and understand your choices, so if they ever have to make them for you, they can do it with the full knowledge that they are doing what you would have wanted.

Further Links and Information:

Changing The Face Of Dying – Blog Post on CPR Facts 
State Specific DNR Information & Links
DNR Tattoos? Why They Don’t Work…
Seven Ponds Resources for DNR and End of Life 
Maine DNR Forms and Information
Information on DNR and CPR from Cancer.net
Ethical Concerns and Discussions with Case Studies on DNR
DNR During Surgical Procedures
DNR Guidebook

Zdogg MD’s Video on End of Life