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6.7 What does "DNR" mean, and when can it be applied? (ER)


This article is from the ER FAQ, by Rose Cooper cooper@acm.cse.msu.edu with numerous contributions by others.

6.7 What does "DNR" mean, and when can it be applied? (ER)

Recently, western medicine has been faced with a bit of a dilemma -- as
our population ages, people begin dying from protracted painful illnesses,
things that didn't happen when everybody died young from communicable
diseases. Now, conditions that didn't have a chance to manifest themselves
before are beginning to occur with more prevalence, and if they're terminal,
they tend to be extremely painful.

One of the fundamental goals of medicine is the relief from suffering,
and to that end, we spend a lot of time working on painkillers and methods
of analgesia. There are some neat ones, like the oral Fentanyl lolly-pops for
patients undergoing chemotherapy, and there are some wonderful drugs out
there to manage pain in just about every kind of case you're going to see.
But suffering is not pain, and pain is not necessarily suffering, so simply
handing out vials of morphine isn't going to relieve suffering.

Terminal patients suffer, there's no question about that. In the hopes
of relieving their suffering, some have elected to ask their doctors to sign
Do Not Resuscitate orders. A DNR is exactly that -- it is a set of
instructions that govern the management of a patient who is suffering from a
terminal condition. You'll sometimes hear these called "no-codes" or
"no-coders." In plain English, a DNR means "Let me die," but since it is a
medical and legal document, it can't be that simple.

And the execution of one never is. A DNR isn't a living will, and in
order to be valid (at least in British Columbia), it has to be written, dated
and signed by the issuing physician. Our ambulance crews and ED staff are
instructed to disregard a DNR if there's any question as to whether or not
it's valid. I believe this to be true of just about all DNR policies in
place today. (Put simply, in the absence of contrary instructions from a
physician, you're getting resuscitated. Sorry.) DNRs do not constitute the
withholding of basic life support functions -- like, say, food or water.

On the alt.tv.er newsgroup, Marny Helfrich writes:

"It was the episode (Ghosts, I think) where Maggie and Jeanie
treat an old lady with end stage Lou Gehrig's disease and a
signed DNR who overdosed on her tricylics (anti-depressent
medication). Maggie is in favor of just letting her go since
she has a DNR and is 'veggie', but Jeannie, who is running the
case, [well, not really. -ms] says 'Do Not Resuscitate' doesn't
mean 'Do Not Treat'. (it means no calling a code (if the patient
arrests), no CPR, no intubation, no shocks, no epi, no thoracotomy,
etc.) and no extraordinary measures like intubation. Jeannie also
says 'We resuscitate suicides. _All_ suicides.'

The issue of who is and isn't DNR and what it means comes up a
lot on the show, actually:

-- the woman in True Lies with cardiac myopathy who refuses
treatment and whose daughter has to watch her die.
-- Jad Heuston in "Whose Appy Now," who wants to be DNR but
whose mother doesn't want to let him die
-- Mr. Johnson in "Let the Games Begin" (or "Don't Ask, Don't
Tell") whose chart they can't find until after Mark has
already put him on a vent.
-- The guy in Ambush with the advanced Esophogeal cancer whose
neighbor paniced and called 911; they didn't know he was DNR
until the teenage wife came in."

In reality, the DNR issue is very muddy, and is of particular concern to
emergency workers who often have to make decisions about the management of a
patient without having anything beyond the immediate history. It's only going
to get more complicated and less clear as time goes on.


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