there are several legally recognized ways for you to give doctors and other
health care providers instructions about the medical treatment you wish to
receive (or do not wish to receive) - before you actually need the care. You
may have heard about advance directives such as living wills and
health care powers of attorney. Ohio law also recognizes another tool
to help you and your physician do effective health care planning for the end
of life. It is called a DNR order.
does DNR mean?
DNR stands for "do not resuscitate." A person who does not
wish to have cardiopulmonary resuscitation (CPR) performed may make this wish
known through a doctor's order called a DNR order. A DNR order addresses
the various methods used to revive people whose hearts have stopped
functioning or who have stopped breathing. Examples of these treatments
include chest compressions, electric heart shock, artificial breathing tubes,
and special drugs.
its DNR Comfort Care Protocol, the Ohio Department of Health has established
two standardized DNR order forms. When completed by a physician (or
certified nurse practitioner or clinical nurse specialist, as appropriate),
these standardized DNR orders allow patients to choose the extent of the
treatment they wish to receive at the end of life. A patient with a DNR
Comfort Care-Arrest Order will receive all the appropriate medical
treatment, including resuscitation, until the patient has a cardiac or
pulmonary arrest, at which point only comfort care will be provided. By
requesting the broader DNR Comfort Care Order, a patient may reject
other life-sustaining measures such as drugs to correct abnormal heart
rhythms. With this order, only comfort care would be provided at a point
even before the heart or breathing stops. Your doctor can explain the
differences in DNR orders.
everyone want CPR?
Although in some cases it does save lives, CPR (cardiopulmonary
resuscitation) frequently is not successful or does not benefit those who
receive it, especially for elderly people or those with serious medical
conditions. Even if the person is revived, he or she can be left with
painful injuries or in a very debilitated state. Resuscitation can
involve such things as drugs, forcefully pressing on the chest, giving
electric shocks to restart the heart or placing a tube down the nose or throat
to provide artificial breathing. People with terminal illnesses or other
serious health conditions may prefer to "die with dignity" instead
of being resuscitated when the end comes. For more information about the
pros and cons of CPR and whether it is right for you, talk with your doctor.
do I make my wishes about CPR known? How do I get a DNR order?
If you do want to receive CPR when it is medically appropriate, you
don't have to do anything. Emergency squads and other health care
providers must provide CPR whenever medically appropriate. If you do
want CPR, you always have the right to refuse it (or any other medical
treatment), but most likely you won't be able to state your wishes when an
emergency happens. Therefore, if you do not want CPR, you should discuss
your wishes with your doctor and talk with your doctor about whether it would
be appropriate for you to have a DNR order - a medical order saying that CPR
should not be given.
doctor will explain the different ways the order can be written and may use
one of the Ohio Department of Health's two standard DNR order forms.
Your doctor is not required to use a standard form. However, an
advantage to using a standard form is that it is easily recognized by
paramedics and other health care workers.
did Ohio adopt a law about DNR?
Because Ohio's 1991 Living Will Law focused on patients in hospitals and
nursing homes, there was uncertainty about the circumstances under which an
emergency health care worker could act on a DNR order and honor a person's
wish not to have CPR. The purpose of the 1998 DNR LAW is to help people
communicate their wishes about resuscitation to medical personnel outside a
hospital or nursing home setting. It allows emergency medical workers to
honor patients' physician-written DNR orders even if they are at home rather
than in the hospital when the heart or breathing stops. The 1998 DNR Law
also protects emergency squads and other health care providers from liability
if they follow their patients' DNR orders outside a hospital or nursing home
will the emergency squad or anyone else know I have a DNR order?
If you are a patient in a hospital or nursing home, the DNR order should
be in your medical chart. You or your family also should notify the
medical staff that you have such an order any time you are admitted to a
facility or are transferred from one facility to another. If you are
receiving care at home, you should tell your family and caregivers where to
find your DNR order. You also may want to talk with your doctor about
getting DNR identification such as a wallet card or bracelet that tells
medical personnel you have a DNR order.
anyone else override my wishes about CPR?
No. You have the right to make your own decisions about your health
care. If you are not able to express your wishes, other people such as
your legal guardian, a person you named in a health care power of attorney, or
a family member can speak for you. You should make sure these people
know your desires about CPR. If your doctor writes a DNR order at your
request, your family cannot override it.
if I change my mind after my doctor writes a DNR order?
You always have the right to change your mind and request CPR. If
you do change your mind, you should talk with your doctor right away about
revoking your DNR order. You also should tell your family and caregivers about
your decision, mark "cancelled" on the actual DNR order, and destroy
any DNR wallet cards or other identification items you may have.
is the difference between a living will and a DNR order?
Both living wills and DNR orders deal with end-of-life decisions, but they
are different. You may complete a living will document yourself even when you
are healthy. Your living will document specifies in advance the kind of
medical treatment you would want if and when you have a terminal illness or
are in a permanently unconscious state and are no longer able to state
your own wishes.
contrast, you do not write a DNR order for yourself. Instead, you make your
wishes known to your physician, who writes a DNR order if and when your
condition warrants it. The DNR order addresses your current state of health
and the kind of medical treatment you and your physician decide is appropriate
under current circumstances.
does a person use a living will to obtain a DNR order?
Ohio has a standard Living Will Declaration form that is widely available.
This standard form specifically directs your physician to write a DNR order
for you if two doctors have agreed that you are either terminally ill or
permanently unconscious. Your attorney and your doctor can help answer
questions about the living will form, including the DNR issue.
does a health care power of attorney differ from a living will? From a DNR
Another kind of advance directive available under Ohio Law is called the
health care power of attorney. This is a document that names another person
(usually a spouse, child, or other relative) to make health care decisions for
you whenever you are unable to do so yourself. These decisions could range
from something as simple as whether to see a doctor to something as
significant as whether to have surgery or to terminate treatment.
will, unlike a health care power of attorney, expresses your wishes directly
to the health care provider and applies only if you are terminally ill or
care power of attorney is not a DNR order, although a health care power power
of attorney ordinarily would permit the person you appoint to agree to a DNR
order for you, if you are unable to express your wishes at the time.
information about advance directives is available in the publication,
"What you should know about...Living Wills and Health Care Powers of
Attorney," published by the Ohio State Bar Association.
use a general power of attorney to address my health care wishes?
No. You may have given your general power of attorney to someone to manage
your financial affairs while you were on vacation or in the hospital. This
general type of power of attorney usually does not address health care issues
and ends if you become disabled.
want a general power of attorney to continue, even if you become
disabled, the document must state that it is a durable or continuing
power of attorney. A health care power of attorney is a durable power;
it continues even after you become disabled and appoints someone to carry out
your health care wishes. Health care providers will more readily recognize
your power of attorney if it is in a separate document expressly addressing
health care matters.
are DNR orders, living wills, and health care powers of attorney used?
A living will might be used to direct a physician to write a DNR order:
Jane decides she does not want CPR to be given to her. She obtains a
living will form and fills it out properly. Later, Jane becomes debilitated
and needs home health care, but she hasn't discussed resuscitation with her
doctor and a specific DNR order has not been written.
the visiting nurse arrives to find Jane is not breathing. At this point, the
nurse begins CPR, because a DNR order has not been written. If Jane is
resuscitated and transferred to a hospital, but remains unconscious, her
doctors may decide she is in a terminal condition. Jane's living will can
serve as evidence that she does not want to be resuscitated in such a
circumstance. Her doctor may write a DNR order so that, if Jane's heart stops
beating again, she will not be resuscitated.
health care power of attorney might be used to authorize a DNR order:
Bill decides that, under some circumstances, he would not want CPR to be
given to him and informs his family of this decision. He obtains a
health care power of attorney form and fills it out properly, appointing his
wife to make health care decisions for him if he is unable to do so.
Later, Bill is seriously injured in an accident and is moved to a hospital
while he is unconscious. His doctors are made aware of the health care
power of attorney, and Bill's wife informs them that Bill would not want CPR
if his heart or lungs should stop functioning. The doctors write a DNR
order, indicating on Bill's medical chart that he is not to be
resuscitated. One day, his heart stops. Since Bill's doctor has
written a DNR order, the health care workers do not resuscitate him.
order alone might be used as in the following example:
John is terminally ill and decides he does not want CPR to be given to
him. He discusses his wishes with his doctor and the doctor writes a DNR
order for John on the Ohio Department of Health form, signs it, and gives it
John becomes debilitated and needs home health care. John informs his
family of his DNR order and gives them a copy. One day, his daughter
comes in and finds that John is not breathing. She becomes alarmed and
calls 9-1-1. Because John's daughter shows the DNR order to the medic
who arrives, the medic does not perform CPR, but does provide John with
can I get further information? Can I draw up my own documents?
The Ohio State Bar Association, the Ohio State Medical Association, the
Ohio Hospice & Palliative Care Organization, and the Ohio Hospital
Association jointly revised a standard Living Will Declaration form and a
standard Health Care Power of Attorney form. These forms may be obtained
from doctors, lawyers, hospitals, nursing homes, and others. You also
may obtain a copy of these forms by mailing a request along with $3 to the
Ohio Hospice & Palliative Care Organization, 1646 W. Lane Ave., Suite 2,
Upper Arlington, Ohio, 43221, or by visiting that organization's Web site at www.ohpco.org.
not have to use the standard forms. For any document to be valid,
however, it must meet certain requirements under Ohio law. If you wish,
your lawyer can prepare a living will and/or health care power of attorney
that is specifically tailored to your situation.
are interested in obtaining a DNR order, you will need to speak with your
doctor, who can complete the appropriate forms for the order, and can tell you
how to obtain a wallet card, bracelet or other DNR identification.
information contained in this pamphlet is general and should not be applied to
specific legal problems without first consulting your own attorney.