Do Not Resuscitate Orders

  • The Canadian Medical Association, Canadian Hospital Association, Canadian Nursing Association, and Catholic Health Association of Canada, in cooperation with the Canadian Bar Association, developed a Joint Statement on Resuscitative Interventions last updated in 1995 and distinguish 4 general categories of Cardiopulmonary Resuscitation (CPR) as a treatment option:
    1. People who are likely to benefit
    2. People for whom benefit is uncertain  
    3. People for whom benefit is unlikely
    4. People who will almost certainly not benefit - patient will either not recover due to underlying illness or will never be able to experience any benefit
  • Do Not Resuscitate (DNR) status should be discussed with the patient, if he or she is competent to do so. Otherwise the discussion should be undertaken with the patient's agent, if one has been appointed, or with the patient's significant others.
  • DNR should be addressed in the context of a broader discussion about the patient's understanding of his or her illness and prognosis, and goals of care.
  • Physicians must give patients a realistic, accurate picture of what's involved in resuscitation, discuss the likelihood of success, risks of neurological damage, the need for life support afterwards and fact that CPR may not only fail to achieve goals but worsen the patient's overall health.
  • Although some patients with metastatic cancer may initially respond to cardiopulmonary resuscitation (CPR), the chances of survival to discharge are minimal to none. The procedure may be physically traumatic, and may lead to the patient spending his or her final hours or days in an intensive care setting.
  • In these situations, patients should be told that CPR would not be offered because it would not be successful. Such a disclosure not only keeps the patient informed and shows respect for them as persons but also gives them the opportunity to answer questions and seek a second opinion.
  • It should be clarified that agreement to DNR status does not mean that patients will not receive other supportive measures.
  • While it is not necessary for the patient to sign consent to DNR status, the discussion should be documented including the names and relationships of those who participated in the discussion, the content of the discussion, and the decision.

When a patient refuses DNR Status

  • The reasons for refusal should be explored.
  • Reasons may include misperceptions about the success of CPR, hopes, fears, guilt, and distrust of the medical system.

Some hospital and professional policies are supportive of physicians unilaterally assigning a DNR status, whether or not the patient consents. This is based on the argument that there is no obligation to provide a treatment that is medically futile. Precedents in Canadian law suggest that a unilateral DNR order can only be justified if the patient is in a persistent vegetative state. Therefore, it is recommended that every attempt be made to resolve disagreements regarding DNR status through open and ongoing discussion. If the patient is already admitted to a palliative care setting and requests that DNR be rescinded, then transfer of care may need to be considered.

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This page was last updated: March 9th, 2005 at 2:13pm.