The term ‘do not resuscitate’ should be laid to rest

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Every year or so there is a story in the news about a hospital being sued for failing to intervene or, alternately, for wrongfully intervening to resuscitate a patient using advanced life support. As experts in end-of-life communication and decision making, we are sometimes interviewed by the press about such cases.

These mix-ups often have at their center patient, family and health-care provider misunderstanding regarding the meaning of a single term: “do not resuscitate,” (DNR) for short. The term DNR means that a patient should not receive cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest (i.e., when the patient has died; is unresponsive, has no pulse and is not breathing).

{mosads}But many patients and health-care providers misinterpret a DNR order to mean that no life support should be given in the event of clinical deterioration (i.e., the patient has not yet died but is getting much sicker).

Some of this is simple ignorance: not knowing the scope of what is included in DNR. Most commonly we encounter people who mistakenly believe that DNR means no intubation for placement on a breathing machine when a patient’s oxygen level is dropping (this, it turns out, has its very own acronym — do not intubate (DNI).

Some of it is bias: knowing the scope of what is included in DNR, but assuming that a patient with a DNR order doesn’t want or wouldn’t benefit from life-extending therapies. Sometimes that assumption is right. But sometimes it’s not.

Worry about this bias may contribute to black patients’ lower use of advance directives compared to white patients. They are right to worry: In one survey of 533 internal medicine residents, doctors were less likely to pursue aggressive or invasive treatment options if the patient had a DNR order.

The evolution of medical terminology contributes to misunderstanding. CPR was first introduced in the 1960s and became standard of care for cardiopulmonary arrest. In the mid-1970’s, concerns that universal CPR might cause more harm than benefit for some patients led hospitals to develop policies allowing patients to forgo CPR, described as “orders not to resuscitate.”

In the 1990’s, however, the term “resuscitation” increasingly began to appear in the medical literature to describe strategies to treat people with reversible conditions, such as IV fluids for shock from bleeding or infection. As the medical terminology surrounding treatments designed to intervene before arrest might occur increasingly appropriated the term “resuscitation’” from its origin in CPR, the meaning of DNR became ever more confusing to health-care providers.

To address this potential for misunderstanding, the Physician Orders for Life Sustaining Treatment (POLST) paradigm separates CPR from other life-sustaining treatments. Specifically, the form reads: “Section A: Cardiopulmonary Resuscitation (CPR) This section only applies when the patient is unresponsive, has no pulse and is not breathing. This is similar to a do not resuscitate order , but a patient only has a DNR Order when they do not want CPR.”

Efforts to change the terminology to “do not attempt resuscitation” or “allow natural death” try to solve some of the misunderstandings, but only confuse people further. The added “attempt” seeks to remind us that CPR is usually not successful. “Allow natural death” seeks to remind us that the procedure is applied when someone has already died. A more obvious solution would be to name it what it means: no CPR.

The ability to designate a preference against CPR is critical for patient autonomy. Eliminating the term DNR and replacing it with “no CPR” would make it more transparent to patients, families and providers what, exactly, is being withheld.

While this change will be burdensome for the state governments, hospitals and nursing homes that would need to modify policies, forms and information technology, health-care systems make changes all the time for even less compelling reasons. For example, the U.S. recently adopted a brand-new diagnosis and treatment code categorization system in order to improve billing detail, estimated to cost more than 1 billion dollars.

So, to reduce confusion and medical errors, “DNR” is a term that should be laid to rest.  

Amber Barnato is the Susan J. and Richard M. Levy 1960 distinguished professor of health-care delivery at The Dartmouth Institute at the Geisel School of Medicine at Dartmouth, a palliative care doctor at Dartmouth-Hitchcock Medical Center (DHMC), and a public voices fellow of the OpEd Project. Maxwell Vergo is director of education in the Section of Palliative Care at the Geisel School of Medicine at Dartmouth and a palliative care doctor at DHMC.

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