In the past, death occurred naturally when a person stopped breathing or their heart stopped beating. In time, however, newer medical interventions were developed that could restart a stopped heart and maintain breathing. This meant recovery for some but not for those with a diagnosis of “brain death” where there was no hope of recovering consciousness or use of mental or physical abilities.
The Do Not Resuscitate Law (DNR), created in New York state in 1987, was the first of its kind. It was groundbreaking in that it allowed an individual or their health care proxy or surrogate to declare their wishes about whether or not they wanted to be kept alive by artificial life support (heart stimulation and artificial respiration) when there was brain death or no hope of recovery due to severe trauma or disease progression. Before the DNR law, only doctors could make that kind of decision.
Under New York law, a DNR instructs medical professionals in a licensed care facility not to perform cardiopulmonary resuscitation (CPR), that is, emergency treatment to restart a person’s heart or lungs when their breathing or heartbeat stops. This means that doctors, nurses, or emergency personnel (EMT or EMS) will not initiate emergency procedures, such as mouth-to-mouth resuscitation, external chest compression, electric shock, insertion of a tube to open an airway, or injection of medicine into the heart or open chest.
Most people encounter a DNR order when they are in the process of completing their Advance Directives. The Living Will section of New York State Advance Directives gives people options about life-sustaining treatments. People can choose to prolong their life, or they can choose not to prolong life in the event that they, as stated in the Living Will, “should be in an incurable or irreversible mental or physical condition with no reasonable expectation of recovery, including but not limited to: (a) a terminal condition; (b) a permanently unconscious condition; or (c) a minimally conscious condition in which I am permanently unable to make decisions or express my wishes.”
They can also indicate the type of medical intervention they do not want by checking specific treatment measures, including cardiac resuscitation and mechanical respiration. However, it’s also common for people being hospitalized for a serious illness, trauma, or any type of surgical procedure to be asked to fill out a stand-alone DNR form indicating their wishes relating to a particular medical situation or hospital stay.
Despite such legislation, almost everyone has heard stories of people who have been resuscitated even though they had previously stated their DNR wishes verbally or in their Living Will. This is most likely to happen in an emergency situation when someone calls 911 and EMT/EMS arrive at a residence or public setting where a person is collapsed and unconscious. Legally, this is considered a “prehospital” setting, and EMT/EMS must provide any necessary life sustaining treatments.
The most important thing people need to understand about care given in a prehospital setting, such as a residence, is that a Living Will or Health Care Proxy (person designated to state the health care wishes of someone unconscious) is NOT valid in prehospital settings. A little known document called a “Nonhospital Order Not to Resuscitate” is a means to avoid having such unwanted treatment measures initiated. The form can be downloaded from the New York State Department of Health web site.
Having this type of out-of-hospital DNR is especially important for someone being cared for in a private home or even someone who needs medical transport from time to time. Copies need to be presented to medical personnel and should also accompany a person during transport to keep everyone involved up to date and aware of the person’s DNR wishes.
End-of-life planning tools like Advance Directives with a Living Will and a nonhospital DNR order provide a sense of reassurance that, when the time comes, a person’s medical care wishes will be honored. As people age, their mental and physical conditions change. To ensure that an individual’s end-of-life wishes reflect their current situation, a yearly review of these important planning documents is strongly recommended along with ongoing discussions with medical providers and loved ones.
Written by Carolyn Van Ness, a retired Women’s Health Nurse Practitioner with experience as a medical journalist and author. Currently her priority is end-of-life education through her efforts as a Death Doula, Death Cafe member, and Hospice volunteer.