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DNR - Do Not Resuscitate

DNRs are Do Not Resuscitate orders. A DNR order on a patient's file means that a doctor is not required to resuscitate a patient if their heart stops and is designed to prevent unnecessary suffering.

The usual circumstances in which it is appropriate not to resuscitate are:

• when it will not restart the heart or breathing
• when there is no benefit to the patient
• when the benefits are outweighed by the burdens

Although DNRs can be regarded as a form of passive euthanasia, they are not controversial unless they are abused, since they are intended to prevent patients suffering pointlessly from the bad effects that resuscitation can cause: broken ribs, other fractures, ruptured spleen, brain damage.

Proper use of DNRs

Guidelines issued by the British Medical Association and the Royal College of Nursing say that DNR orders should only be issued after discussion with patients or their family.

Although it may be difficult to have discussions with patients and their relatives about whether to revive or not, doctors accept that this is no reason why discussions should not take place.

The most difficult cases for discussion are usually those involving patients who know they were going to die, are suffering a lot of pain, but who could live for several months.

Dr Robin Loveday, a consultant says, "that is the situation where you really need a lot of discussion with the patient and their relatives to help them make a decision as to whether, if they do suffer a cardiac arrest, it is appropriate to have another go to give them a few more months of life."

Guidelines

The UK medical profession has quite wide guidelines for circumstances in which a DNR may be issued:

• if a patient's condition is such that resuscitation is unlikely to succeed
• if a mentally competent patient has consistently stated or recorded the fact that he or she does not want to be resuscitated
• if there is advanced notice or a living will which says the patient does not want to be resuscitated
• if successful resuscitation would not be in the patient's best interest because it would lead to a poor quality of life

In the UK, NHS Trusts must ensure:

• an agreed resuscitation policy that respects patients' rights is in place
• a non-executive director is identified to oversee implementation of policy
• the policy is readily available to patients, families and carers
• the policy is put under audit and regularly monitored

Abuse of DNRs

The clear guidelines on DNRs had to be firmly restated in 2000, after a number of seemingly healthy patients discovered they had 'do not resuscitate' or DNR orders written in their medical notes without consultation with them or their relatives.

There was further concern when it emerged that junior doctors had sometimes made DNR decisions because senior doctors were unavailable.

Age Concern warned that the UK's elderly feared they were at risk of not being revived simply because of their age.

Arguing that DNRs might be a form of ageism in the NHS, a spokeseman said "Age Concern will not rest until the 'writing off' of patients' lives on the basis of their age has been stamped out."