Benefits and Drawbacks of Do Not Resuscitate (DNR) Orders

Takeaways

• Do not resuscitate (DNR) orders instruct health care providers not to perform CPR or other life-saving measures if a patient's heart or breathing stops.
• DNRs offer a balance of benefits, including patient autonomy and avoiding unnecessary suffering, as well as drawbacks, such as potential for undertreatment or misinterpretations by health care providers.

If you stop breathing or your heart stops, health care providers will typically do everything they can to save your life, including cardiopulmonary resuscitation (CPR). However, some people choose to have a Do Not Resuscitate (DNR) order in place.

What Is a DNR?

A DNR order is a legal and medical document. It instructs health care providers not to use CPR or other measures to revive you if your heart or breathing stops. These lifesaving measures may include keeping your airway open with intubation, putting you on a ventilator, or using a defibrillator to shock your heart. Setting up a DNR involves a conversation with your provider about the benefits and drawbacks of these interventions.

DNR orders are on the rise, with a 36 percent increase from 2016 to 2023, according to Komodo Health. Research shows that people choose to have a DNR for a variety of reasons – from quality-of-life concerns to financial and family considerations. Some older people with terminal illness see death as natural and inevitable and resuscitation measures like CPR causing unnecessary hardship.

Agreeing to a DNR order is the most prevalent among older adults. Eighty-five percent of DNR holders are 65 and older and 83 percent are Medicare-insured.

What to Consider With a DNR

For some, the drawbacks of resuscitation outweigh the potential benefits of attempting to prolong life. Patients may have concerns about what their life will be like following resuscitation, want to avoid pain, or are worried about the financial toll of their medical care on their family members. For example, someone with a terminal illness may have a DNR in place in advance of an adverse health event to help avoid unnecessary suffering.

While movies show CPR as saving lives consistently, in reality, CPR does not always work. People tend to overestimate its effectiveness. The American Red Cross reports that while CPR can revive people who experience cardiac arrest, survival rates are relatively low: 10 percent for those outside of the hospital and 21 percent for those in the hospital.

Meanwhile, CPR can potentially cause injuries, including broken ribs and brain injuries from oxygen deprivation during the incident.

Intubation and ventilation come with a loss of independence as well as risks of side effects that can cause additional suffering. Side effects of intubation include bleeding, infection, and tearing of the throat.

However, informed consent is an important aspect — and advantage — of a DNR. Before cosigning a DNR form, a doctor should discuss with the patient how resuscitation would affect their health. This allows the individual making the DNR to better understand the effects of their decision.

Another positive is that DNRs can be flexible. They can be suspended during procedures like surgeries and revoked if the patient changes their mind.

Downsides of DNRs

In theory, a DNR is supposed to be limited to specific interventions that would save a person’s life, like CPR. Yet having a DNR in place can make health care professionals assume that a patient does not want other treatments that are technically beyond the scope of a DNR, such as bloodwork or additional visits with specialists. Research consistently shows that DNRs are associated with worse health outcomes and death.

A DNR is also specific, limited to measures such as CPR, intubation, and ventilation. Many health care decisions can have quality versus quantity of life considerations that are outside the scope of a DNR.

For instance, imagine a person with dementia and terminal cancer has a DNR in place. They may want to avoid chemotherapy and would prefer palliative care that keeps them comfortable as they approach death. However, their mental capacity has declined so they cannot communicate, and their spouse wants to keep them alive longer and try the treatment. In this case, having a DNR would not prevent the treatment.

Although a DNR can prevent a person from being resuscitated against their wishes, further advance care planning is necessary to protect one’s autonomy more fully and ensure medical treatments reflect their intentions and values.

Estate Planning Considerations

A DNR may therefore serve as only one aspect of a more comprehensive plan. Creating an estate plan with advance directives in addition to or instead of having a DNR order allows a person to express their wishes for care should they become unable to communicate.

A living will is a type of advance directive through which a person can limit the kinds of care they would like to receive. For instance, they can restrict treatments to those that would provide comfort and decline treatments that would only lengthen their life without improving its quality.

When a person also has in place a health care power of attorney — another type of advance directive — these documents work together to support their autonomy. In a health care power of attorney, a patient can appoint a surrogate decision-maker to act on their behalf. This allows them to select a trusted person to follow their wishes regarding medical decisions.

The patient can discuss their plans with their health care agent ahead of time. The power of attorney for health care can also outline the patient’s preferences for medical treatment, organ donation, and burial.