only preparation of legal documents but also discussions with family members and physicians about what the future may hold for people with serious illnesses, how patients and families want their beliefs and preferences to guide decisions (including decisions should sudden and unexpected critical medical problems arise), and what steps could alleviate concerns related to finances, family matters, spiritual questions, and other issues that trouble seriously ill or dying patients and their families. Impediments to advance planning and the implementation of written directives may be less a matter of law than of ordinary inertia or unwillingness to consider unpleasant matters. The rest of this section discusses resuscitation orders, living wills, designation of surrogates, and the Patient Self-Determination Act of 1991.

Do Not Resuscitate Orders

Do not resuscitate orders or DNRs are orders placed by a physician with a patient's or surrogate's consent into the patient's treatment chart. As discussed in Chapter 2, it is not unusual for severely ill patients, who may be dying from any of a variety of diseases, to suffer cardiac or respiratory arrests. The normal action when this occurs is called a "code."6 DNRs, or "no-codes," inform hospital staff or other caregivers that, in the event of such an episode, no attempts at revival should be made. Even when attempted, success rates of cardiopulmonary resuscitation are often low, especially for elderly patients (Murphy et al., 1989). For that reason, DNRs are sometimes called DNARs or "Do Not Attempt to Resuscitate" orders.

Because DNRs are physicians' orders, they come out of the clinical rather than the legal tradition. They thus have more in common with orders for medication or lab tests than they do with such legal documents as living wills or durable powers of attorney. Additionally, many hospitals had DNR options in place before they were required to do so by law. DNRs might, however, have some legal significance, if courts take them into account when determining whether a patient's preferences have been followed. Also, because the decision by the physician to place the DNR in the chart should be made in consultation with the patient and should reflect a patient's decision to forego certain forms of life-prolonging treatment, DNRs share with living wills and durable powers of attorney a role in the process of advance care planning.

6  

Caregivers attempt, through the insertion of breathing tubes and a pump, or by electric shock to the heart, to revive the patient. These attempts may stabilize the patient or may result in actual damage, leaving the patient alive but in a worse condition than before the code.



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