Out of Hospital DNR May Avoid Disrupting Wish to Die at Home

By Wesley E. Wright and Molly Dear Abshire, as published in the Houston Chronicle Senior Living Section on July 1, 2002.

Advances in medical technology have contributed to increasing the average lifespan in our society. While most would agree that a longer life is desirable, there are times when people may choose to refrain from receiving the intervention of life sustaining procedures. At such times, a ìDo Not Resuscitate" (DNR) order makes the patientís wishes clear.

A DNR order instructs health care personnel not to use specific types of procedures when the patientís heart or lungs stop working in the hospital. The DNR is a formal notation on the patientís chart, made by a physician, ordering health care personnel not to use specific types of procedures, generally referred to as ìcardiopulmonary resuscitation", or ìCPR", when the patientís heart or lungs stop working. CPR includes a lengthy list of treatments that may be used in an emergency situation to respond to a patientís sudden loss of oxygen to the brain either because of a lack of uptake from the lungs or because blood flow has become inadequate.

DNR orders frequently are issued for patients receiving acute or long term care in a hospital setting. The subject of much debate, the use of DNR orders is determined on the basis of three common rationales. One rationale frequently used suggests that the treatment would be of no medical benefit to the patient, meaning that resuscitation of the patient would probably be unsuccessful. Another rationale indicates that there would be poor quality of life after CPR; as a result of the cardiac arrest and the ensuing CPR effort, the patientís life would not be acceptable, although it may be prolonged with the treatment. Yet another rationale concludes that there is poor quality of life before CPR, which is indicative of the poor condition of the patient prior to any CPR emergency and the resistance to prolong the condition.

The standard procedure in all hospitals is to administer CPR until a DNR, also called a no code order, is given. Physician and patient should determine whether the patient would prefer a DNR order as opposed to regretting not having had one after CPR is administered. DNR orders should not be issued without consultation with and consent of the patient. If the patient lacks decision making capacity, the order can be requested by the agent under a medical power of attorney or other surrogate decision maker.

Patients sometimes learn too late that a DNR issued by a doctor in a hospital will not be recognized by emergency medical services (EMS) responding to the call. Generally, EMS personnel are required to attempt to resuscitate or use other life-saving treatment unless a doctor is present and instructs them not to do so. Even if the patient has a living will, or Directive to Physicians and Family or Surrogates, EMS technicians must continue to revive and transport the patient to the hospital. This policy has the potential for disrupting an individualís wish to be allowed to die at home. For this reason, a person who desires a DNR at home should consult his or her physician about preparing an Out-of-Hospital DNR, which Texas law specifically allows.

The Texas statute defines an ìOut-of-Hospital setting" as a location where health care professionals are called for assistance, including long-term care facilities, in-patient hospice facilities, private homes, hospital out-patient or emergency departments, physicianís offices, and emergency vehicles during transport.

In Texas, a competent person who has been diagnosed by a physician as having a terminal condition may at any time execute a written Out-of-Hospital DNR order. This document instructs health care professionals, acting in and out of a hospital setting, to withhold CPR and other life-sustaining procedures. The declaration must be witnessed and executed by two witnesses and the patientís physician.

A person who has a valid DNR order may wear a DNR identification device around the neck or around the wrist. The presence of such a device on a personís body is conclusive evidence that a valid Out-of-Hospital DNR order has been executed by or on behalf of that person. Responding health care professionals are required by law to honor the DNR device as evidence of the written order.

Texas law also provides for parents, legal guardians, or a managing conservator to execute an Out-of-Hospital DNR for a minor. It is important to know, however, that the desire of a competent minor or adult supercedes the effect of an Out-of-Hospital DNR order executed or issued by or on behalf of the person when the desire is communicated to responding health care professionals.