DO NOT RESUSCITATE (DNR) ORDER What it does, what it doesn’t do Do you have one?? Should you? Resuscitate: revive (someone) from unconsciousness or apparent death. What is a DNR Order? DNR order = A doctor’s order to not provide CPR Cardiopulmonary resuscitation Alerts emergency personnel that you do not want cardiopulonary resuscitation (CPR) in the event that your heart has stopped or your airway is blocked. It is a medical order only valid if signed by a doctor. If you do not have a DNR order, emergency medical personnel must use all available measures, no matter how invasive, to save your life. This is the default position. WHO IS IT FOR? DNR orders are used primarily by people who are already critically ill and feel strongly that they do not want life-prolonging treatment when close to death. When the heart stops many feel this is a natural death. Some are concerned that brain damage would occur before CPR was started. They could be resuscitated but only the brain stem would work, none, or few, cognitive functions would remain — a persistent vegetative state. If you do not have a DNR order, emergency medical personnel must use all available measures, no matter how invasive, to save your life. Another side — To be resuscitated, do nothing. Using a DNR form outside a hospital. If you are not hospitalized, you can complete a California DNR form that alerts paramedics who respond to emergencies at home, in hospice facilities, or elsewhere. It's important that you also get a MedicAlert or other bracelet, anklet, or necklace to make your wishes immediately apparent. Keep in mind that, to be valid, your DNR form must be signed by a doctor or other approved medical professional. For more information about DNR orders, talk to your doctor. Why would you have a DNR order? You are not in good health You are very old and frail You have a terminal illness You are worried that your brain would not have oxygen by the time you were resuscitated You remember these young women: Karen Quinlan Nancy Cruzan Terry Schiavo Getting a DNR order in the hospital. When you are admitted to a hospital, your doctor can add a DNR order to your medical record. Ultimately, only 5–10% of patients in cardiac arrest will survive after an attempted resuscitation. Cardiopulmonary resuscitation (CPR) = chest compressions, often with artificial ventilation, to try to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. CPR involves chest compressions for adults between 2 inches and 2.4 inches deep and at a rate of at least 100 to 120 per minute.[ CPR alone is unlikely to restart the heart. Its main purpose is to restore partial flow of oxygenated blood to the brain and heart. The objective is to delay tissue death and to extend the brief window of opportunity for a successful resuscitation without permanent brain damage. Administration of an electric shock to the subject's heart, termed defibrillation, is usually needed in order to restore a viable or "perfusing" heart rhythm. Defibrillation is effective only for certain heart rhythms, namely ventricular fibrillation or pulseless ventricular tachycardia, rather than asystole or pulseless electrical activity. Purpose: To instruct EMS personnel regarding a patient's decision to forgo resuscitative measures in the event of cardioplumonary arrest. The form does not affect the provision of life sustaining measure such as artificial nutrition or hydration or the provisions of other emergency medical care, including treatment for pain, difficulty breathing, major bleeding, or other medical conditions. The DNR must be signed by the patient or by the patient's legally recognized health care decision maker if the patient is unable to make or communicate informed health care decisions. The patient's physician must also sign the form, affirming that the patient/legally recognized health care decision maker has given informed consent to the DNR instruction. The DNR form should be clearly posted or maintained near the patient. What a DNR order does NOT do: The form does not affect the provision of life sustaining measure such as artificial nutrition or hydration or the provisions of other emergency medical care, including treatment for pain, difficulty breathing, major bleeding, or other medical conditions. EMTs, if called, can make you comfortable but will NOT restore cardiac function or breathing, if you have a DNR order. You can let people around you NOT to call 9-1-1 if your heart stops. If you want no treatment you can spell that out in your directive AND with you health care agent. DNR applies ONLY to restoring heart function and breathing. Having DNR in your POLST or Directive is OK. But, because of time crunch the EMTs should know immediately if you want DNR. The medallion or wrist bracelet are the main ways to inform the EMTs NOT to start resuscitation. It is better to have the directive on YOU rather than your refrigerator. Unless they are absolutely certain that a qualified DNR advance directive exists for that patient, EMS personnel will proceed with CPR. Time may be too short to contact your DPOA. Unless they are absolutely certain that a qualified DNR advance directive exists for that patient, EMS personnel will proceed with resuscitative measures. Common complications due to CPR are rib fractures, sternal fractures, bleeding in the anterior mediastinum, heart contusion,hemopericardium, upper airway complications, damage to the abdominal viscera - lacerations of the liver and spleen, fat emboli, pulmonary complications - pneumothorax, hemothorax, lung contusions. The most common injuries sustained from CPR are rib fractures The brain may sustain damage after blood flow has been stopped for about four minutes and irreversible damage after about seven minutes. Typically if blood flow ceases for one to two hours, then body cells die. Therefore, in general CPR is effective only if performed within seven minutes of the stoppage of blood flow.The heart also rapidly loses the ability to maintain a normal rhythm.. Following cardiac arrest, effective CPR enables enough oxygen to reach the brain to delay brain stem death, and allows the heart to remain responsive to defibrillation attempts What about other legal documents, such as a Durable Power of Attorney for Health Care (DPAHC?) or “living wills”. Are they acceptable in place of the Pre-Hospital DNR form? While such official documents are generally respected by EMS personnel (check with your attorney and with the local EMS agency in your county), it is important to keep in mind that most EMTs or paramedics do not have the legal training needed to interpret such documents, and more importantly, do not have the time to read a lengthy document and make a life-or-death decision on the scene. If in doubt, the EMS personnel will err on the side of the patient and provide resuscitative measures. Orders for partial resuscitation (eg, "do not intubate") have evolved from DNR orders. What measures: Resusciative measures to be withheld include chest compressions (CPR), assisted ventilation (breathing), endotracheal intubation, defibrillation, and cardiotonic drugs (drugs which stimulate the heart). (DNR) Form is an official State document CAN THE STATE DNR FORM AND/OR MEDALLION BE USED IN A SKILLED NURSING FACILITY OR HOSPICE? YES. THE ADOPTION OF THE FORM FOR USE BY SUCH FACILITIES IS ENCOURAGED; HOWEVER, MANY FACILITIES DO NOT KNOW OF THE FORM, OR THEY HAVE THEIR OWN IN PLACE, WHICH MAY NOT BE RECOGNIZABLE TO THE EMT OR PARAMEDIC. THE BEST WAY TO ENSURE THAT YOUR WISHES ARE HONORED IS TO BE SURE THE FACILITY IS AWARE OF AND PROVIDED A COPY OF THE DNR OR POLST FORM AND THAT THEY ARE CLEARLY POSTED OR MAINTAINED NEAR THE PATIENT. YOUR DNR ORDERS ARE IN PLACE FOR AS LONG AS YOU WISH THEM TO BE; YOU NEED ONLY TO DESTROY THEM IF YOU WISH TO STOP THEM. YOU SHOULD ALSO CONTACT YOUR DOCTOR’S OFFICE AND FAMILY IF YOU DO SO. The medallion or bracelet can be ordered by sending a copy of the signed DNR order to the address shown (MedicAlert Foundation.) The jewelry ordered this is way IS official and will be honored. MEDICALERT FOUNDATION 5226 PIRRONE COURT SALIDA, CA 95368 1-888-633-4298 CPR may succeed in inducing a heart rhythm that may be shockable. In general, CPR is continued until the person has a return of spontaneous circulation (ROSC) or death. THESE are the only ways to make sure you are NOT given CPR. None of these are valid, they are NOT ORDERS..