Do Not Resuscitate / Do Not Hospitalize / Do Not Intubate (DNR/DNH/DNI)

A client asked last week whether he had properly signed his own DNR and DNI orders. We asked if he meant a “do not resuscitate” and “do not intubate” order. He confirmed that was what he thought he had signed. It made us think we need to look at the advance directive issue and update some of our earlier posts on the subject.

Do Not Resuscitate (DNR)

Lots of clients want to execute a “Do Not Resuscitate” order for themselves. But that involves a fundamental misunderstanding of what DNR orders are, who creates them and how they are used.

First of all, a Do Not Resuscitate order is not something you sign for yourself. It is a medical order, signed by your doctor and directed to the other treatment staff, not to begin cardiopulmonary resuscitation if you experience cardiac arrest or stop breathing. You can request that your physician enter such an order, but  you can’t order it yourself. The confusion on this point is widespread: one online source muddies the water by asserting that “A do-not-resuscitate (DNR) order is a legal document signed by you and your provider.” Nope. You might sign a consent (assuming you are competent to do so). Or your health care agent might do so (if you are not). But the DNR order is a doctor’s order.

And note that the Do Not Resuscitate order directs withholding of CPR, use of electronic defibrillators (including AEDs), and potentially to a breathing tube. But is not the “plug” that most people say they would want  to have “pulled.” Even a properly executed and effective DNR order would not, by itself, result in removal of a feeding tube — or even removal of an artificial breathing machine once it is in place.

So what is the anxious client to do?

Medical providers will often react to an emergency with an emergency response. Artificial breathing can often become the end-point of a succession of actions attempting to save a patient’s life in the heat of the medical moment. You should appoint a health care agent. Give them the power to refuse consent, and to authorize removal of the breathing apparatus if it is instituted.

It is critically important that you name an agent who will assert your wishes. It is also important that you fully convey those wishes to your agent. Frank, thorough discussions with your agent and the rest of your family — AND your medical providers — is the surest way to accomplish refusal of cardiopulmonary resuscitation. If you think some family members will object, they are the ones you most need to talk with in advance.

Arizona does permit a form that sounds a little like a DNR order. It is the “pre-hospital medical care directive,” and is almost always called “the orange form.” It is unique to Arizona, though other states have something superficially similar called the POLST paradigm. The orange form (which you do sign yourself) directs paramedics and emergency room physicians not to begin CPR or advanced resuscitation techniques. But it doesn’t say anything about your treatment after the ambulance and the emergency room.

Would a “Do Not Intubate” order help?

You could include a “do not intubate” (DNI) instruction in your health care power of attorney and/or living will. Intubation can include both assisted breathing (endotracheal intubation) and tube-feeding. You could express your wishes that neither be used — assuming that is your wish. And tubes are the “machines” that most people imagine when they say they want machines turned off.

A DNI instruction (not really an order) can be powerful. Your health care agent can use it to argue for removal of tube-feeding and/or artificial breathing. They can also use it to resist the implementation of those technological treatments.

You can be as precise (or imprecise) as you wish. You can indicate your preference in favor of one kind of intubation and opposition to the other. Or you can even authorize your agent to give either (or both) a trial period. Or you can leave the decisions up to your agent without guidance — though that’s not our favorite approach.

“Do Not Resuscitate” can mean that you don’t want chest compressions or endotracheal intubation. Do not intubate, written on your chart in the nursing home or hospital, might prevent endotracheal intubation or tube feeding.

What is a “Do Not Hospitalize” instruction?

You could include a “do not hospitalize” (DNH) instruction in your advance directives. If you are at home, or in assisted living or even a skilled nursing facility, they probably can’t intubate you without transferring you to the hospital. So staying out of the hospital can be an effective technique.

Will a DNH instruction guarantee that you won’t be hospitalized or intubated? No. But your odds definitely go up. And they go up even more if your health care agent is active, protective and assertive. And if they know what you want (or, more to the point, don’t want).

What did we tell our client?

Armed with that background, we could explain to our client that he had signed what he needed. His health care power of attorney authorized his agent to withhold intubation and even hospitalization. And, while he couldn’t sign his own Do Not Resuscitate order, he had given his agent authority to consent. What else did he need to do? Talk with his physician and his agent, and make sure his family knew his wishes. That’s all he needed. It was also all he could do.