Under Florida and federal law, a competent adult has the right to choose the kind of health care he/she wishes to receive, reject, or discontinue. Your advance health care directives are documents that tell your family and physicians your preferences for medical treatment if a situation arises in which you cannot communicate – for example, if you are in a comatose state. There are several types of advance directives. Each applies to a specific type of medical circumstance. In this post, we focus on just one advance directive: The Do Not Resuscitate Order (DNRO). Here is what you should know about this often-misunderstood document.
What Does A DNRO Accomplish?
First, understand that a DNRO is not the same as a living will or a health care surrogate. The DNRO applies only to a situation in which a person has ceased breathing or is having cardiac failure. In that circumstance, the DNRO instructs emergency medical personnel and other health providers to withhold cardiopulmonary resuscitation (CPR). If emergency personnel cannot verify that a patient has a valid DNRO, they are legally bound to resuscitate the patient.
Who Creates and Signs a DNRO?
The DNRO is a medical document signed by the patient OR by the patient’s health care surrogate. It must also be signed by a licensed physician. It does not need to be witnessed or notarized. It must be printed on yellow paper. You do not need a lawyer to create a DNRO. Click here to download the form from the Florida Department of Health. Or call 850-558-9514 to request one.
The Potential Downside of Resuscitation: It Isn’t Like This On TV
Most non-medical people do not fully understand the nature of CPR and its outcomes. A 2015 study, It Isn’t Like This On TV: Revisiting CPR Survival Rates Depicted on Popular TV Shows, found that in the television universe, the survival rate for those who get CPR is 70%. Public perception aligns with that statistic: the study also found that the public believes the chances of a patient surviving after CPR is about 75%.
There is no doubt that CPR saves lives. Who can forget that CPR saved Buffalo Bills safety Damar Hamlin when he suddenly collapsed on the field in January 2023? However, it is important to fully understand that for an elderly or frail person, CPR does not necessarily produce results as favorable as Hamlin’s. A 2015 study in Sweden found that when CPR was administered to patients in their 70s outside a hospital setting, the survival rate was 6.7%. For patients age 90 and over, the survival rate was just 2.4%. The percentages improved only slightly when CPR was administered in a hospital setting.
Even if an older person is resuscitated by CPR, the procedure has a substantial chance of leaving the patient in a diminished state with slim chance of recovery. CPR involves compressing the chest forcefully by two inches, one hundred times per minute. This aggressive process can produce fractured or cracked ribs, punctured lungs, pulmonary hemorrhage, liver lacerations, broken sternums, and even permanent brain injury. Once patients or health care surrogates become aware of these statistics for the frail and elderly, more than half reject CPR, according to a February 1994 article in The New England Journal of Medicine.
We are reminded of a late client of ours, who at age 100 was physically and mentally fit. He played golf four times a week. He was very eager to sign a DNRO. He said he’d had a “good run,” and if he experienced cardiac arrest on the golf course, so be it. Under no circumstances did he want to risk living in a diminished condition following administration of CPR. On the other hand, we have other clients and their health care surrogates who strongly believe that “Where there is life, there is hope” no matter the circumstances, and reject the notion of a DNRO. They want CPR administered and want to be kept going no matter what.
Make Sure The DNRO Is Visible And Will Be Honored
If you create a DNRO or if you are a health care surrogate who signs one for someone else, it is vital that the document be readily visible to emergency medical personnel. As noted before, it must be on yellow paper. For someone who is in bed in a facility or a hospital, posting the DNRO at bedside or on the patient’s door makes it easy to spot. But in other settings, including the home, it can be tricker to make sure emergency personnel see it. Most people put the form on their refrigerator or tape it to a wall near their bed; these are locations EMTs are trained to look for them. Your DNRO can also be laminated and carried on your person.
Situations are not uncommon in which emergency medical staff have resuscitated a person despite the person having a valid DNRO, either because the document was not noticed or there was confusion over whether it should be honored. One such case occurred in Florida in 2022: Celeste Salanitri, age 81, had end-stage Parkinsons Disease and had a valid DNRO. When she collapsed on the floor of her assisted living facility, the EMT’s were summoned. Despite seeing her DNRO, the EMT’s administered CPR in the ambulance because they believed that the facility director directed them to do so. Salanitri survived, but had to be intubated following CPR. She spent twelve days in this condition before she died. This was exactly the kind of situation she had wanted to avoid with her DNRO. Said her cousin: “While it might not have been their intention, they brought her back so that she could die slowly.”
It is important to realize that if your loved one has a DNRO, that does not mean you should refrain from calling 911 if the person has a medical emergency. EMT’s can administer pain medication and provide other kinds of help, even if they do not administer CPR.
It can certainly be emotionally challenging to ponder these situations for ourselves or for our loved ones. We hope this blog post is useful to you and your family, and helps everyone understand both the benefits and risks of CPR, so an informed decision can be made about signing a DNRO.