Understanding DNR Orders in Hospital Situations: Guidelines and Variances

When an individual with a Do Not Resuscitate (DNR) order comes into the hospital, the response might vary based on several factors. This article provides a detailed explanation of how hospitals, emergency medical services (EMS), and healthcare providers respond to such cases in different regions and circumstances. It also delves into the nuances of POLST, MOLST, and the importance of clear communication.

General Understanding of DNR Orders

A DNR is a directive that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if the individual's heart stops or they stop breathing. The implementation of a DNR order depends on the specificities provided, which could include details like under what circumstances resuscitation should or should not be performed. This article focuses on the standard protocol, varying across different states and localities, particularly in Pennsylvania (PA).

DNR Orders and Cardiac Arrest

In the case of a cardiac arrest, if a valid DNR order is presented, healthcare providers in PA would generally not initiate resuscitation. Instead, they might call law enforcement or the coroner and ask the family to decide on the course of action for their loved one. A valid DNR order in PA must be a DNR bracelet, necklace, or a signed document from the patient, healthcare proxy, and physician. A tattoo, while perhaps personal, has no legal standing in this context.

POLST and Varying Protocols

While a DNR order is specific to CPR, another document, the Physician Orders for Life-Sustaining Treatment (POLST), can offer a broader scope. POLST can include specific instructions that might override a DNR order in certain life-threatening situations. For instance, a patient with a POLST might receive artificial ventilations if they are struggling to breathe, although CPR might not be initiated if their heart stops. This highlights the nuanced nature of end-of-life care and the importance of clear directives in writing.

Regional Variations and Other Considerations

While the core principles of DNR and POLST orders remain consistent, regional and national policies vary. In New York State (NY), the multi-Order for Lifesustaining Treatment (MOLST) form allows patients and healthcare proxies to specify various actions that should or should not be performed. This form offers a more detailed and personalized approach to end-of-life care.

When a patient is still alive and has a DNR order, it should be treated as such, provided the patient can communicate their wishes clearly. However, in cases where the patient is unable to speak and the family demands resuscitation, it becomes a more complex situation. In some locations, EMS might request a copy of the DNR order with clarifications of what actions should and should not be taken. These requests help ensure that the patient's wishes are honored while respecting the family's demands to the extent possible.

Practical Examples and Precedents

The implementation of these policies can be illustrated through specific examples. For instance, a patient in hospice care might still receive necessary treatments, such as a broken leg, despite having a DNR order. This underscores the importance of distinguishing between different conditions and ensuring a comprehensive approach to patient care.

Conclusion

The response to a DNR order in a hospital setting involves a combination of patient wishes, legal documentation, and regional protocols. Whether in PA, NY, or elsewhere, the key to successful care is clear communication and understanding of these nuances. By adhering to established guidelines and respecting patient preferences, healthcare providers and EMS can ensure that they are supporting both the patient's and the family's needs during this sensitive time.