Understanding CPR and DNR

What is CPR?

CPR stands for cardiopulmonary resuscitation. CPR is the process of attempting to restart the heart and/or breathing after one or both has stopped (referred to as cardiac or respiratory arrest). CPR can include a number of different treatment techniques:

Manual (performed using the hands) chest compressions
Defibrillation (a brief electric shock applied to the chest to restore a normal heart rhythm)
Administration of drugs to stimulate the heart
Mouth-to-mouth breathing
Bag-valve mask ventilation (the use of a football-size bag, attached to a face mask, that is squeezed by hand to push air into the lungs)
Insertion of an oropharyngeal airway (a plastic device placed into the mouth to keep the throat open during bag-valve ventilation)

If CPR is able to restore a normal heart rhythm, but the patient is not able to breathe on his or her own, the patient may be placed on a mechanical ventilator, or artificial respirator. A tube (called an endotracheal or ET tube) is placed through the mouth and down the trachea (the windpipe). The tube is then connected to a ventilator that pumps oxygen into the lungs. Being placed on a ventilator is sometimes referred to as being "on life support."

How effective is CPR?

CPR can save lives and is most effective in the case of a heart attack or accident in an otherwise healthy person. CPR is significantly less successful in someone who is in poor health due to an advanced illness, such as cancer. Fewer than 5% of people with a serious illness will recover enough to be discharged from the hospital following CPR.

For someone in the terminal or end-stage of cancer, the body's organs, including the heart and lungs, will begin to fail as death approaches. Even if CPR is able to restart the heart and/or breathing, the heart or lungs will likely fail again soon. CPR may also be only partially successful, and the person may suffer brain damage (due to a lack of oxygen to the brain) or may have to remain on a ventilator indefinitely.

What is a DNR order?

DNR, which stands for do not resuscitate, is a type of advance directive, a document that instructs medical personnel that you do not wish to receive CPR—to be resuscitated—if your heart and/or breathing stop. If you are in a medical setting, such as a hospital or nursing home, and your heart and/or breathing stop, medical personnel will automatically perform CPR unless you have a DNR order.

Unlike other advance directives that are written and signed by the individual (such as a living will or a Durable Power of Attorney for Health Care), a DNR order must be completed and signed by your doctor or other health-care provider, such as a hospice nurse practitioner. Once completed, your DNR order is added to your medical record.

Health personnel can only follow a DNR order if they know one exists. It is important to notify doctors and nurses that this has been discussed and that you have a preference to avoid CPR. In cases where a patient is transferred from one facility to another, or if a new health-care team takes over in the same hospital, it is recommended that you reiterate that this issue has been addressed and that you have a strong opinion in favor or against the use of CPR. It may be useful, too, to remind your family members, so they know of your wishes and can help advocate for you if you are unable to do so.

Points to think about when considering a DNR order

Ideally, decisions about end-of-life care should be made early in the care process before there is a need for them. If you wait until a crisis occurs, it may be too late for you to communicate your wishes about a DNR order or other advance directives. Although discussing death and dying is difficult and sad, it is recommended that people living with advanced cancer revise and review their wishes for end-of-life care with family and health-care professionals. Goals and plans can be revised to reflect new events or changing preferences. Starting the dialogue early on will only strengthen your relationship with your health-care team.

As you make your decision, consider the following points:

Do you have strong personal, religious, or spiritual views about dying and care at the end of life?
Would CPR likely enable you to return to a quality of life and level of activity that would be acceptable to you?
Are there important tasks that feel unfinished? Do you need to say things to loved ones or complete financial tasks that will allow them to live better after you die?
If CPR were partially successful, would you want to be placed on a ventilator?
Do you have strong feelings about dying at home versus in a hospital setting (CPR may increase the likelihood of dying in a hospital setting)?

Open communication with your loved ones and with your doctors and nurses will allow them to guide you through the complicated maze of instructions, paperwork, and formalities. More importantly, it will allow them to serve you well and personalize your care.

Calling 911 and out-of-hospital DNR orders

DNR orders do not apply to emergency medical services (EMS) personnel responding to a 911 call, they are only valid in a hospital. EMS personnel will perform CPR on a person in cardiac or respiratory arrest, even if the person has a DNR order. A 911 call requires an immediate response and EMS personnel do not have the time to verify a DNR order or to identify the person they are treating. Therefore, caregivers and family members caring at home for someone with a DNR order are advised not to call 911 if the person's heart or breathing stops.

Some states have started out-of-hospital DNR programs that allow EMS personnel to honor DNR orders in people's homes. Out-of-hospital DNR orders may include a special DNR form that is posted in the person's home and/or a special DNR bracelet worn by the individual. Similar to in-hospital DNR orders, the patient's doctor must sign out-of-hospital DNR orders. In some states, out-of-hospital DNR orders are also called comfort care DNR orders, as they allow EMS personnel to provide palliative care to make the person as comfortable as possible, and to help relieve the symptoms and side effects that result from the cancer and cancer treatment. Talk to your doctor or hospice nurse, or contact your state's health department, to find out if your state has an out-of-hospital DNR program.

Additional resources

Lance Armstrong Foundation: Planning Your Medical Future

Family Caregiver Alliance: End-of-Life Choices: CPR & DNR, End-of-Life Choices: Holding on and Letting Go, and End-of-Life Decision Making

Saint Luke's Health System eLibrary: Should I receive CPR and mechanical ventilation? (In search field, type in "Should I receive CPR?")

American Cancer Society: Types of Advance Health Care Directives and Frequently Asked Questions