Do Not Resuscitate (DNR)/Do Not Attempt Resuscitation (DNAR)

A. Do Not Resuscitate (DNR)/Do Not Attempt Resuscitation (DNAR) is defined as the withholding of cardiopulmonary resuscitation (CPR) in the event of a patient’s sudden cardiopulmonary arrest. CPR may include closed chest compression, tracheal intubation and ventilation, and electrical and pharmacologic cardiac stimulation according to Advanced Cardiac Life Support (ACLS) standards.

B. A DNR/DNAR order is applicable only in the event of a cardiopulmonary arrest and does not refer to withholding or discontinuing other supportive therapies that may be in place (such as the ongoing administration of cardiotonic drugs, an endotracheal tube, etc.).

C. The attending physician/provider must provide the DNR/DNAR order, either in writing or verbally. A verbal DNR/DNAR order may be taken by a licensed nurse and co-signed by the physician/provider within 24 hours.

D. The physician/provider may write a DNR/DNAR order only when:

• Agreed to by a fully informed patient with decision-making capacity, or
• In accordance with an advance directive or the expressed wishes of the patient, or
• Agreed to by the designated healthcare agent(s), for a patient without decision-making capacity.  Washington State law defines the order of priority for designated healthcare agent(s) as:

1. A legal guardian with healthcare decision-making authority.
2. The person with healthcare decision-making authority named in the Durable Power of Attorney.
3. The spouse
4. Adult children (when more than one person, all must agree)
5. Parents (when more than one person, all must agree)
6. Adult brothers and sisters (when more than one person, all must agree)

• He/she deems CPR to be futile and life-sustaining treatments would be of no benefit to the patient. There is no obligation to render futile care. Futile care is any treatment that is not likely to benefit the patient, is one that the patient does not have the capacity to appreciate and/or is very likely to require permanent dependence on medical care with the burden outweighing any benefits.

E. If a patient is admitted to the hospital with a valid Physician Orders for Life-Sustaining Treatment (POLST) form, the orders therein are to be honored until the attending physician writes the admitting order and clarifies patient’s DNR/DNAR status.

F. The physician/provider will ensure documentation in the medical record reflects the evaluation, discussion, and decision-making process.

G. The DNR/DNAR order may only be rescinded by the attending physician/provider, in consultation with the patient or designated health care agent(s).

H. The DNR/DNAR order itself should be clearly documented and communicated.

I. Unless otherwise clarified and documented, a DNR/DNAR order is temporarily suspended while a patient is undergoing a surgical procedure and receiving care within the surgical operatory. If DNR/DNAR is present, there will be clarification of wishes with patient/designated health care agent(s) prior to surgery. The DNR order is again in full force when the patient leaves the surgical operatory.

J. Modifications to Full Resuscitation (Full Code) or DNR/DNAR orders will not be accepted.

K. Under specific circumstances, limited interventions may be ordered.

A. Patients may have DNR/DNAR and still receive curative or restorative interventions related to their disease process and/or a new diagnosis or problem. The extent of any supportive care and/or interventions is defined by a patient’s goals of care.

B. The focus of care for the patient where the goals of care is comfort only, the DNR/DNAR is to provide support for comfort measures, assist with pain and symptom management, and create a supportive environment for the patient and family.

C. The attending physician is to be notified of:

• Any communication from the patient, family, or designated health care agent(s) regarding a desire to change DNR status, or
• Any change in patient condition that may relate to establishing, clarifying or rescinding DNR status.

A. The patient’s autonomy and expressed wishes are to be honored. In the case of the patient without decision-making capacity the designated health care agent(s) will make decisions guided by the patient’s prior directives and best interest.

B. The informed decision of a patient with decision-making capacity will prevail over that of others. The patient or the designated health care agent(s) has the duty to communicate truthfully with caregivers.

C. The medical, nursing, and clinical staff has the duty to render care according to their professional standards and to respect the patient’s wishes whether expressed by the patient directly, or through an advance directive or the designated health care agent(s). Whenever possible, these discussions should be held in a timely fashion and not when the patient is in extremis.

D. Doctors, nurses, and clinical staff may not be coerced to act in a way that is not in accordance with their value systems. (See Conflict Resolution below).

A. End-of-Life/DNR decision making is often stressful and conflicts may arise. Ideally conflicts are resolved via discussion between identified parties. If conflict resolution is not accomplished successfully, the following avenues are available:

• Clinical staff may activate the policy for “Ensuring Appropriate Patient Care” (in the Administrative Policy Manual) or seek consultation from Nursing Executive and/or the Clinical Ethics Committee.
• Medical staff may seek consultation from Chief of Service, Chief of Staff, the Clinical Ethics Committee, another physician, or Nursing Executive as needed.
• Patients/families may be referred to Department Manager or Nursing Executive.

B. If a conflict remains unresolved, arrangement may be made to have the patient’s care transferred to another physician or to another institution as necessary. If such action is requested by patient/family, assistance will be provided by hospital staff as needed.