Do Not Resuscitate (DNR) means that if the heart stops, the patient does not want Cardio-Pulmonary Resuscitation (CPR) to try restarting the heart. (University of Washington, American Heart Association, Red Cross, Mayo Clinic). The American Heart Association's goal is that no one should die from heart stoppage.
Many people, young and old, have DNR orders, because they do not want CPR if their heart stops, and prefer to die without the attempt at resuscitation. Here are some of the tradeoffs:
Sources: 2017 data outside hospitals from MyCARES, 2017 Non-Traumatic National Survival Report. 2016 data in hospitals from pages e357, e365, Heart Disease and Stroke Statistics-2018 Update. 2014 data on 64% revival in hospitals from "Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest." 2000-2009 data on change in mental problems in hospitals calculated from "Trends in Survival after In-Hospital Cardiac Arrest."
Broken Bones: An overlapping 8% to 9% of survivors have broken bones from CPR, and 91-92% do not.
Heart stoppages are rare in hospitals, one per 1,700 patient days (page e356)
We can do better: Rates will improve as the best practices spread. Survival in hospitals is better on weekdays and in some hospitals. Survival outside is better for some ambulance services.
Mental outcomes can improve in the first 6 months after hospital discharge.
CPR survivors (whose heart stopped in a hospital) had about the same frequency of mental problems before and after CPR, based on 12,000 survivors 2000-2009:
before CPR after CPR
16% 18% Severe Mental Problems (dependent on others)
30% 31% Moderate Mental Problems (can independently do activities of daily life)
53% 50% Mild or No Mental Problems
Organ Donation: 2015 guidelines say liver and kidneys may be donated if CPR is done, even without success, and all organs can be donated if the patient revives but dies in the hospital. Donations may still be limited by hospital abilities and patient condition.
More Details on CPR
CPR includes strong repeated pushes inward on the chest of an unconscious patient, while the patient lies on a hard surface (not on a bed), in a safe place, until the patient recovers. As soon as a defibrillator (AED) arrives, it gives an electric shock, which can help convert some unhealthy heart rhythms to a healthy rhythm. After defibrillation the patient may still need more chest compressions, a breathing mask or tube and injections. Quick insertion of a breathing tube used to be standard, but it did not save lives or reduce brain damage. Even after recovery, the heart needs help to recover for a few days, involving many steps such as oxygen, drugs, imaging the blood vessels, and maybe cooling the body.
"Vomiting is the most frequently encountered complication of CPR. If the victim starts to vomit, turn the head to the side and try to sweep out or wipe off the vomit. Continue with CPR... Even CPR performed on strangers has an exceedingly rare risk of infection. There is NO documentation of HIV or AIDS ever being transmitted via CPR."
Most nursing homes lack defibrillators; a few have them, so your choice of nursing home affects how long CPR may take until medics arrive with a defibrillator. Patients need to be put immediately on a bed board or the floor, since CPR on a bed does not compress the chest enough.
People often write limiting directives, such as DNR orders, on the assumption they'll come into play for old age, coma or dementia. But heart attacks may come any time, putting the directives into effect, so directives need to treated seriously.
Patients who want full care need to be ready for doctors' resistance. A Houston study said, "All physicians reported interpreting requests to 'do everything' as a 'red flag', a sign to more thoroughly explore what 'everything' meant to the patient or family." Caucasian doctors said such families "might be in denial." Hispanic and African American doctors said such requests could show suspicion of doctors.
Researchers have found that as people decline, they're comfortable with more care, just as people with disabilities are, "Patients often cannot envision being able to cope with disability... However, once patients experience those health states, they are often more willing to accept even invasive treatments." The researchers also found that for irreversible or terminal illness, "physicians and surrogates frequently have difficulty determining when patients are in these states." These are reasons to choose a representative you trust, who knows your goals.
Advance Directives for CPR or DNR
Another article discusses medical representatives and directives, and you can put your instructions online for immediate access if medics look.
If you choose DNR, it needs to be signed by a doctor, and a copy of the signed DNR needs to be in your wallet or purse, as well as online, for immediate access. Emergency medics need to see a doctor's signature, in order to honor a DNR. Pittsburgh (UPMC) offers a card to print on pink cardstock and keep with you, with room for a doctor's signature.
Some people might prefer CPR, with its chances for good results, combined with an advance directive for suicide if they are among the few who develop a severe disability. Directive and suicide laws do not allow that combination. Even so, you can discuss with your medical representative and doctors whether you want your directive to say, if CPR causes severe mental deterioration, do you want "palliative sedation ... to manage intractable symptoms, maybe through reduction of consciousness or complete unconsciousness"? Directives often call for relief of pain or discomfort "even if it hastens my death". However most patients with mental deterioration turn out to enjoy their lives: the "disability paradox," where people with a severe disability are usually happy in their life, and say they have a good quality of life, so they want to continue, even in the most severe locked-in state. Their unhappiness, if any, comes from pain, fatigue, lack of control or purpose, and isolation, which can all be minimized.
Directives reduce care long before death: 60% of US surgeons will not offer a high-risk operation to patients whose advance directives limit followup care.
20% of patients with a DNR order "wanted a trial resuscitation for cardiac arrest," which they will not get, so patients need to decide carefully about DNR. Among patients with a "Do Not Intubate" order, 58% wanted intubation in some scenarios. This 2013 study has had no follow-ups.
Patients with a Do Not Resuscitate (DNR) order die sooner, even when they are not very sick, because they are denied many treatments besides CPR, so DNR prevents fine-tuning exactly what you want and don't want. A 2016 editorial from AMA says that:
Resuscitation and Myths
Resuscitation works well enough so your chances of leaving the hospital alive are, on average:
At 26% survival, hospitals need to give CPR to 4 patients to prevent one death. This is far better than other treatments. Even 9% survival in nursing homes means 11 are treated to save one, which is better than most treatments.
Number Needed to Treat (Number of patients treated, to save one life):
JAMA 2018: Most heart treatments need to treat more patients, for many years, to save a life:
Bandolier at Oxford (also has Number Needed to Treat for many other treatments):
CPR's 9% to 26% odds also look good compared to disasters, where teams search as long as there is even a 1% chance of rescuing survivors. Or if you had cancer, would you choose a treatment with 9% or 26% odds of remission after brief treatment, over an alternative of immediate death?
Trying CPR is cheap, $181 under Medicare. Further care costs much more, but is only done on the living, or to save organs for transplant.
Doctors' doubts about CPR success contrast with their endorsement of cancer screening, though that rarely saves lives.
Survival rates vary for different types of patients. Survival is average or better for patients with heart attacks, heart failure, stroke, or diabetes. Survival is also higher (25%) when patients are on cardiac monitors, which detect stoppages immediately.
Survival rates are below average, even in a hospital, for:
Ribs are broken in 8% to 9% of patients who are revived by CPR outside of hospitals:
Defibrillators are in many public places, but a 2004 survey found them in less than a seventh of US nursing homes (except Seattle, which has made a city-wide push for defibrillation).
Defibrillators can help patients whose heart starts fibrillating, and who don't have an implanted defibrillator. Automated external defibrillators (AED) have pads to stick on the patient's skin which measure the patient's heart rhythm. If it is fibrillating, the machine advises a shock which comes through the same pads. The shock stops the heart, so it can restart itself correctly.
Ventricular fibrillation (VF) decays quickly to a stopped heart, so getting the AED and attaching it within 1-3 minutes is essential.
However even when the heart is completely stopped (asystole), 13% survive to leave the hospital alive if it stopped in a hospital, 4% in a nursing home, and 2% in the community, because of injections and chest compressions. These figures are striking, though they don't affect decisions for or against resuscitation. The rhythm isn't known until after resuscitation starts, so people need to decide their CPR preferences based on the total survival rate.
The PulsePoint app lets 911 call citizens near a cardiac arrest who've been trained in CPR.
Three professors from Columbia and Harvard recommend (JAMA 3/7/2012, emphasis added):
"Physicians should not offer CPR to the patient who will die imminently or has no chance of surviving CPR to the point of leaving the hospital."
TRAINING FOR RESUSCITATION
A Regina Saskatchewan orientation video shows a team coming to revive a "patient" in a hospital. They use an actor and a dummy, showing a wide array of techniques available. The doctor handles timing of an AED, which is handled automatically by the AED outside a hospital. 14 minutes.
U of California San Diego (UCSD) orientation video on how a trauma center helps patients. They do not show resuscitation, since it seems patients would be resuscitated by ambulance crew, though it may be needed again in the trauma center. They show how they evaluate the various wounds. 16 minutes.
REAL EXAMPLES OF RESUSCITATION
The Heart Association has training videos. The PulsePoint app lets 911 call citizens near a cardiac arrest who've been trained in CPR.
52-year-old Tony Gilliard from South Carolina narrates a video of his heart stoppage while playing basketball in 2013. CPR and AED brought him back. 2 minutes. youtu.be/v=YrBq_sFV3LA
62-year-old John Ellsworth's heart stopped in a British street. He needed 3 AED shocks to revive, then was taken to a hospital where they treated him, and eventually placed a defibrillator in his chest. 10 minute video narrated by the BBC series Real Rescues. youtu.be/nxpYuVr53zQ
71-year-old Nebraska lobbyist Tom Vickers collapsed in 2008 from a heart attack at the state Capitol. CPR and AED administered by a doctor on duty revived him. He was taken to a hospital, where they found 99% blockage in an artery. Video from security camera. no sound. 3 minutes.
News article: journalstar.com/news/local/quick-action-by-many-helps-lobbyist-survive-heart-attack/article_c64eb533-d5bb-5eae-99ee-54a7b12a414e.html
51-year-old Chris Solomons in Britain had a heart attack and felt his hands shake and his limbs tingle. He worked at a site which dispatched helicopter medics, and he was still not feeling well when he got there. The medics there took an EKG, which did not look right so they were getting ready to get him to a hospital, but he collapsed. They used CPR and 2 AED shocks to revive him, and flew him to a hospital where doctors found a blocked artery and opened it with a stent. 13 minutes. He says,
A man collapsed in a car, and police arrived to pull him from the car. They and a passing nurse gave CPR and AED. The wife panicked, swore, prayed, and yelled at her husband not to leave her. An ambulance arrived and took over. The man lived and left the hospital in a few days. The nurse and police were given awards for their fast action. It seems to be filmed from a camera mounted on the first police car. 4 minutes.
An Augusta Georgia video shows two patients in the emergency room at the same time. Many of the comments heard on the video use abbreviated medical language. 11 minutes.
45-year-old runner who collapsed at a race got CPR immediately from other runners, and AED after 12 minutes. He was taken to the hospital and revived with cooling treatment. Revival required a breathing tube, which was removed 2 days later.
65-year-old woman collapsed at home with husband, went several minutes without CPR. An ambulance crew got some response from her heart, using sodium bicarbonate and another medicine, but she died in the emergency room. youtube.com/watch?v=NWKyXYnvlpM
CPR saved the life of reporter Steve Lopez, and he wrote how it saved an ex-judge who collapsed while driving alone.