Purpose: The purpose of the order is to allow a cancer patient to experience a natural death while under the care of medical personnel. The order is enacted only when the patient stops breathing or the heart stops beating because of the terminal illness. Even with a DNR, a natural death may not be allowed if heart or respiratory failure is caused by an unrelated event such as a car accident. Health care professionals providing care to patients without DNR orders, regardless of the severity of disease, are legally required to provide cardiopulmonary resuscitation (CPR) and perform medical interventions at the time of death. These efforts must not only be initiated but also be continued until they are deemed futile by the physician or a designated professional.
The extraordinary measures performed by health care professionals in the event of respiratory or heart failure include CPR and placing the patient on life support. These procedures are invasive and often considered painful. Appropriately performed CPR can cause broken bones and punctured organs even in generally healthy individuals, such as accident victims. Such injuries are more likely to occur in frail individuals who are near death. Life support may consist of intravenous (IV) drugs that cause the heart to continue to beat. Without the medications, the heart will stop and death will be irreversible in a few minutes, even with aggressive treatment. Mechanical ventilation (a breathing machine) is another form of life support. A tube is inserted into the patient’s throat and is attached to a mechanical ventilator. If the patient needs the ventilator for a long period of time, a tracheostomy (a surgical opening in the neck) will be created to attach to the machine. The ventilator causes artificial breathing. Without the machine, the patient would be unable to breathe, and life would not be sustained. Life support requires that an individual has continuous care, often in a medical facility.
Procedure: In the United States, an adult who receives health care services and wants to be allowed to die a natural death must consult with a physician before a DNR order is written. The majority of individuals with DNR orders have a terminal illness such as advanced or aggressive cancer. Electing to die a natural death allows the individual to have some control in the death process. Most individuals report they would prefer to die in their own home rather than in a hospital or nursing home. Terminally ill patients may be able to stay at home if nursing or other care is provided. If they want to die naturally at home, a DNR is needed. These patients may be transferred to the hospital if a higher level of care is needed. The DNR order must be provided to ambulance personnel transporting the patient to prevent unnecessary interventions in the event of respiratory or cardiac failure on the way to the hospital.
The first step in obtaining a DNR order is for cancer patients to discuss the issue with their medical provider. The best time to discuss these issues is before death is imminent. This allows for a less emotional and more rational discussion of the situation. Any adult who is mentally competent and his or her physician can determine if a DNR order is appropriate. If the patient is not competent to discuss the issue, family members may approach the physician. If the patient (or family if the patient is not competent) and physician are in agreement, the physician can write the DNR order. If the patient disagrees with the physician’s recommendations, he or she may select another health care provider or the physician may ask for a medical ethics consultation. The consultation is provided by a professional in medical ethics who is not involved in the direct care of the patient.
Medical care: Many cancer patients and their families are afraid of having a DNR order. There is concern that inadequate medical care may be provided to those who have a DNR order. However, these orders do not interfere with routine medical care. Care of the patient changes only in its focus, not in its provision. Pain management, comfort, and end-of-life issues become the priority rather than disease management. The patient may have extensive health care needs, such as personal grooming, bathing, and feeding, and these activities are continued. A DNR order prohibits only extraordinary measures that would prevent death or prolong life unnecessarily. For the DNR order to be active, a copy of the order must be submitted when entering home health care, hospice, or any other medical facility. If the order is not present and respiratory or cardiac failure occurs, cardiopulmonary resuscitation is medically obligated. A DNR order can be revoked by a patient at any time.
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