The idea around decisions or orders to Allow Natural Death (AND), or Do Not Resuscitate (DNR) is to address your preferences or personal wishes in the event of a sudden and immediately life-threatening loss of heartbeat and/or ability to breathe.
In previous posts, we discussed directives you can make which speak to your wishes on matters affecting your medical care.
This post specifically discusses sudden, unexpected and potentially immediately fatal events occurring outside the setting of a hospital or ER, and your wishes in such an event. More particularly, this pertains to a sudden loss of heartbeat and ability to breathe such as might occur in a massive heart attack.
This may be ultimately expected in a terminal illness such as advanced cancer, or may be entirely unexpected.
Doctors generally ask about your preferences since we do not wish to withhold care from you that you want, but we also do not wish to perform heroic or even desperate procedures on you that you actually do not want.
Certainly, you should realize that a decision by you to allow a natural death or not to resuscitate does not affect your care in other matters such as your cancer, pneumonia or hip fracture. As our nursing colleagues rightly point out, "no resuscitation does not mean no care"!
Something to be mindful of in your decision-making is what is occurring during a loss of breathing and pulse and during CPR.
A sudden loss of breathing and pulse can occur for a variety of reasons, but while it is occurring, there is a significant loss of oxygen supply and blood flow to your brain. CPR is an attempt to maintain circulation of blood to the brain while awaiting definitive attempts to restore normal heart rhythm by delivering an electrical shock. This is known as defibrillation (or "shock paddles", as seen on TV). Medicines given if this occurs in a hospital are largely given in order to maximize blood flow to the brain. It is ultimately timely defibrillation that can restore normal heart rhythm with intact brain function.
Note the emphasis on the intact brain function part.
The tricky part here is that your brain can only go for 5 minutes without good blood supply before permanent brain damage starts to occur. Past this limit, the longer the duration of sub-optimal blood flow the more extensive the damage. For a worst-case scenario, think Terri Schiavo.
Even in the best of circumstances where this occurs in a hospital, the odds of going home alive and with an intact brain are about 15%.
If this occurs outside a hospital (such as at home, a friend's house, a movie, a restaurant, etc.) the lack of immediate access to a defibrillator makes an enormous difference.
If you survive long enough to make it to an ER, and survive long enough to actually be admitted to the hospital, your odds of eventually going home alive and with an intact brain are only 2-8%. This is because your valuable 5 minute window of opportunity is already gone by the time paramedics can arrive even if someone has immediately called 911.
Once paramedics arrive, they are legally required to initiate CPR and resuscitative efforts. If, given the aforementioned discussion, you would wish for them to do so, you do not need to take any action at all.
On the other hand, if you would NOT want them to do so, you need a signed order from a doctor instructing them not to start resuscitative efforts.
This handout and sample form can be used if you feel that you would not want paramedics to start resuscitation for such an event in your home. It only requires your signature (or your caregiver's) and your doctor's signature.
(Paramedics will still come to your home and provide the usual help in all other matters! Signing this does not mean that they will not come to your home, or help you if you have fallen down or have a medical problem.)
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