DNR orders, POLST and ethical dilemmas

1. You findA patient is in cardiac arrest and a valid DNR order is presented to you.You doFollow it. A do not resuscitate order is a legal document, typically signed by the patient and a physician, saying the patient does not want resuscitative efforts. Read it, because some DNR orders set conditions.
2. You findA patient is in cardiac arrest. The family says there is a DNR, or asks you not to resuscitate, but there is no legal document present.You doProvide care and begin resuscitation. A family member's oral request alone is not enough to withhold resuscitation.
3. You findThere is a valid DNR, but the family is distressed and demands that you resuscitate anyway.You doContact medical direction. The physician may need to speak with the family directly.
4. You findThe patient has a POLST form.You doTreat it as medical orders that go beyond resuscitation: it also covers other end-of-life preferences, such as artificial feeding and antibiotics, for when the patient cannot speak for themselves.
5. You findYou face a problem with no protocol: for example, you see a colleague hide a serious medication error.You doIdentify your options, weigh patient welfare, safety and legal duty against the competing pressures, and choose the course that best protects the patient, even when it is uncomfortable. Here, that means reporting it.

• An advance directive is written and signed in advance of the event it governs. A DNR order is one form of it.
• DNR orders vary. One might direct resuscitation only if the arrest is witnessed, and not if the patient is found already in arrest.
• POLST (Physician's Orders for Life-Sustaining Treatment; the national program now calls it "portable medical orders," and the name differs by state) is broader than a DNR. In some states physician assistants and advanced practice nurses can sign it, so learn the rules where you work.
• A living will is a signed statement of preferences about long-term life support and comfort measures. It typically applies in the hospital, not to prehospital care.
• A health care proxy is a person the patient has named to make decisions if the patient becomes unable to.
• The decision rule: without an actual legal document in hand, provide care. It is better to be criticized for trying to save a life than for letting a patient die.
• Ethics: patient safety, and honesty about the care actually given, come before loyalty to a colleague.

The wrong idea: If the family tells me the patient had a DNR and did not want CPR, I should respect their wishes and stop.

What is actually true: A family member's word alone, without the legal document present, is not enough to withhold resuscitation. Start care. If a valid document is produced, it can be honored then; if you withhold care and no valid order exists, the patient has lost the only chance they had.

A DNR order is a legal document, a form of advance directive, saying the patient does not want resuscitative efforts; some DNR orders set conditions. A POLST is broader and covers other end-of-life treatment choices as well. A living will usually applies in the hospital, and a health care proxy is a person named to decide for the patient. The rule in the field: a family's oral request without the legal document present is not enough, so provide care. If the family wants a valid DNR ignored, contact medical direction. For ethical dilemmas with no protocol, identify the options, weigh patient welfare, safety and legal duty, and choose what best protects the patient, as when you report a colleague's serious medication error.

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