AMERICAN NURSES ASSOCIATIONPosition Statement on Nursing Care and Do-Not-Resuscitate (DNR)* Decisions Summary: Nurses face ethical dilemmas concerning confusing or conflicting DNR orders and this statement includes specific recommendations for the resolution of some of these dilemmas. Although cardiopulmonary resuscitation has been used effectively since the 1960s (Kouwenhoven et al., 1960), the widespread use and possible overuse of this technique and the presumption that it should be used on all patients has been the subject of ongoing debate (Hayward, 1999; Lederberg, 1997). The DNR decision should be directed by what the informed patient wants or would have wanted. This demands that communication about end of life wishes occur between all involved parties [patient, health care providers [HCPs], and family; the latter as defined by the patient], and that appropriate DNR orders be written before a life-threatening crisis occurs. Background: Expectations that the Patient Self-Determination Act would facilitate communication about DNR orders among HCPs and patients led to a disappointing clinical reality, as research has shown low rates of advance directive (AD) completion and poor ability of Ads to influence physicians’ decisions about writing DNR orders (Hakim, et al., 1996; Jacobson & Kasworm, 1999); Prendergast, 2001). This is partly due to the confusion surrounding how written Ads are interpreted, how DNR decisions are made and implemented, and how DNR itself is defined (Hakim, et al., 1996; Heffner, et al; 1996; Teno, et al., 1998). Some have argued that HCPs focus too narrowly on the DNR order, which typically prohibits attempts to restore cardiopulmonary function in the event of a patient’s cardiac or pulmonary arrest. Instead, they assert that the focus should be on the goals of medical treatment, for example: § § § Life prolongation regardless of quality; Comfort and symptom palliation; or Aggressive attempts to sustain life with the understanding that life-sustaining technology will be withdrawn if it does not meet the goals agreed upon by the HCP and patient or family; (Choudhry, 2003; Fischer, et al., 1997; Kolarik, et al., 2002; Prendergast, 2001). Recommendations In view of the confusion and complexity that continue to surround DNR decisions and their implementation, ANA makes the following recommendations: 1. Whenever possible, the DNR decision should be a subject of explicit discussion between the patient and the family (or designated surrogate) acting according to the patient’s wishes, if known, or alternately, the patient’s best interest, and the health care team. The efficacy and desirability of CPR attempts, a balancing of benefits and burdens to the patient, and therapeutic goals should be reviewed and updated periodically to reflect changes in the patient’s condition (JCAHO. even when these wishes conflict with those of HCPs and families. such as a progress note in the medical record indicating how the decision was made. Effective communication of DNR orders among staff that protects against patient stigmatization or confidentiality breaches. Guidance to HCPs who have evidence that a patient does not want CPR attempted but for whom a DNR order has not been written. Specifically. patients undergoing surgery or invasive procedures).considered. 5. The role of various HCPs in communicating with patients and families about DNR orders. Nurses need to be aware of and have an active role in developing DNR policies within the institutions where they work. that CPR attempts would not be medically effective. 2002).” Inappropriateness of “slow codes” or “show codes” (i. consider or clarify: § Potentially confusing orders such as “chemical code only. Guidance to HCPs on specific circumstances that may require reconsideration of the DNR order (e. 1992).” or “withdrawing .. There should be no implied or actual withdrawal of other types of care for patients with DNR orders.” “doing nothing. Attention to language is paramount.. and euphemisms such as “doing everything.g. but do not intubate. An exception to this is if CPR attempts are requested via an AD or surrogate but one or more physicians determine.” or “resuscitate. The needs of special populations (e. pediatrics).. § § § § § § § § 4. (Ditillo. as allowed by state law. attempts to demonstrate or mimic a response. Required documentation to accompany the DNR order. Effective communication of DNR orders when transferring patients within or between facilities. policies should address. 3. that stops short of a full resuscitation effort). DNR orders must be clearly documented. perhaps for the benefit of family members.g.e. The choices and values of the competent patient should always be given highest priority. 2. communicate known information that is relevant to end of life decisions.. encourage patients to think about end of life preferences in advance of illness or a health crisis.A. Choudhry. D. the nurse must be involved in the planning as well as the implementation of resuscitation decisions. § § § 8. *Other terms include “Do Not Attempt Resuscitation” and “no CPR” References § American Nurses Association (2001). S. Unilateral do-not-attempt-resuscitation orders and ethics consultation: A case series. together with adequate palliative end of life care. families and/or HCPs concerning DNR orders (Casarett & Siegler. Nurses have a duty to: § educate patients and their families about the use of biotechnologies at the end of life. B. Washington. Should there be a choice for cardiopulmonary resuscitation when § § § . Choudhry. M. The appropriate use of DNR orders. CPR for patients labeled DNR: The role of the limited aggressive therapy order. can prevent suffering for many dying patients who experience cardiac/pulmonary arrest. Nurses should participate in an interdisciplinary mechanism (e. N. 2003). As the primary continuous HCP in health care facilities.” to indicate the absence or presence of a DNR order should be strictly avoided. Code for Nurses with Interpretive Statements. P. advocate for a patient’s end of life preferences to be honored. et al. and to implement an AD..care. Critical Care Medicine 27(6): 1116-20. DC: American Nurses Publishing Casarett. and Ads. (1999). interdisciplinary ethics committee) for the resolution of disputes among patients.K. 7.A. (2003). Exclusive of condition-specific DNR orders (Choudhry. (2002). & Siegler. Clear DNR policies at the institutional level that include the basic features that ANA recommends will enable nurses to effectively participate in this crucial aspect of patient care. to discuss them with their HCP(s) and family.. & Singer.g. Annals of Internal Medicine 138(1):65-68 Ditillo. 6. 1999). a patient who has a DNR order and who suffers cardiopulmonary arrest for whatever reason should not have CPR attempts performed. termination of treatment decisions.. SUPPORT Investigators... and physician’s judgments. B. (1996). N.. Kolarik. 178:84-97 Lederberg. Journal of Palliative Medicine 5(1):107-16. F. K. Advance care planning.. & Lynn. R. Journal of General Internal Medicine (8):618-24 Kouwenhoven.S... Critical Care Medicine 29(2 Suppl).. Spernak.death is expected? Revisiting an old idea whose time is yet to come. (1996). W. J. (2000). Home Healthcare Nurse 18(8):532-9 Prendergast... G. Arnold. Hakim. Quality Management in Health Care 7(4):13-20 Joint Commission on the Accreditation of Health Care Organizations (1992) “Nursing Care Standards. L. J. & Lynn. The kitchen table discussion: A creative way to discuss end-of-life issues.J. “Closed-chest cardiac massage. Fischer. (1997). C.13(7):439-46 § § § § § § § § § § § .. & Casey. W.B..S. R. J. § Fischer.S. Annals of Internal Medicine 125(4):284-93. J... 1960. M. Illinois.. Jr. L. (1998) Role of written advance directives in decision making: Insights from qualitative and quantitative data. (2001). T.A. Wenger. (1997). progress. E.” Accreditation Manual for Hospitals.B. R. Can goals of care be used to predict intervention preferences in an advance directive? Archives of Internal Medicine 157(7):801-7.D. Harrell. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. S. M.C. Effect on communication of treatment limitations. J. “ Journal of the American Medical Association. British Journal of Nursing 8(12):810-14 Hayward.. Kasworm. Emanuel. Califf.. Journal of General Internal Medicine 1998 July.S.M.E. L. & McSteen.R. M..J. Teno. J. Stoeckle. & Hanusa. (1999).R. Doctors in limbo: The United States DNR debate. promise. Oak Bluffs Terrace. Stevens. P. Heffner. A. Barbieri. Jr. Procedure specific do-not-resuscitate orders. (1999). Jude.. & Knickerbocker.L. Alpert. N34-39 Teno. G. Layde. R. H. (2002). K. Knaus. Cardiopulmonary resuscitation: Are practitioners being realistic? Archives of Internal Medicine 156(7):793:97 Jacobson. Advance care planning: Pitfalls.H. prognoses.F. R. J..M. Factors associated with do-not-resuscitate orders: Patients’ preferences.E. Psychooncology 6(4):321-28 Norlander. Connors.. Phillips.M.G. G. May I take your order: A user-friendly resuscitation status and medical treatment plan form. DC 20024 (202) 651-7000 . S. Nursing and the Patient Self-Determination Act. Promotion of Comfort and Relief of Pain in Dying Patients. 1991 3. Washington. 1991 G:\POSITION\HUMANRT\DNRREVISED2004. Code for Nurses With Interpretive Statements. Revised 2003 Revised Position Statement Task Force on the Nurse’s Role in End of Life Decisions ANA Board of Directors The Advisory Board of the ANA Center for Ethics and Human Rights Related Past Action: 1.Effective Date: Status: Originated by: Adopted by: Revised by: 1992. Revised 1995.doc American Nurses Association 600 Maryland Avenue. 2001 2.W.