The DNR order

My experiences lately on the "medicine wards" have made me think more about the DNR order ("Do Not Resuscitate"). It's beginning to become quite apparent that the medical order for DNR is neither understood nor utilized properly by both patients and family members, as well as by physicians, who ought to be the ones to understand it and explain it. In the next couple of blogs I want to try to explore this issue and get some feedback.
The DNR order (also called DNAR in some hospitals for "Do Not Attempt Resuscitation") is a medical directive for a patient in a hospital or chronic care facility which instructs the care providers NOT to attempt to resuscitate a patient in the event that the patient's heart stops beating or the patient stops breathing.
A resuscitation commonly involves the following:
-CPR (chest compressions and mouth-to-mouth),
-Defibrillation or Pacing (electric shocks to try to get the heart going again), and
-Intubation (putting a tube down the throat and hooking it up to a ventilator to breathe for the patient).
The majority of patients in a hospital do not have a DNR order on their charts, which means that if they "code" (cardiac or respiratory arrest) the doctors and nurses will use the resuscitation protocol to try to "bring them back." Naturally, this is the default for anyone coming into a hospital, at least in North America today, as far as I know. No one is a default DNR because of age or medical condition, as far as I know. That being said, there are certainly some medical conditions in which resuscitation attempts will be futile, and we should consider them at some point. But first,
How does someone get a DNR order?
1. First thing to remember is that the vast majority of patients in normal hospitals (excepting children's hospitals) are elderly people. Most of them are sick with more than one, often four or five, illnesses and on multiple medications. Many of them are "frequent flyers" who come into hospital anytime their heart failure gets out of control or they get a pneumonia. For these patients you can bet they have at best one or two years left to live, but no one can predict that they this admission will be their last. (On that note, studies show quite conclusively that doctors are notoriously bad at judging prognosis for heart disease and the like -cancer is easier. Judgement gets worse the better a doctor knows the patient. And errors are made equally on both sides - patients die a lot faster when we expect them to pull through just fine, and they pull through when we were sure they were breathing their last breaths.)
2. There are some people who openly say - I don't want anything done: if I die, let me die in peace. Few and far between.
3. For most patients, it is the responsibility of the admitting doctor to ascertain with the patient what direction will be taken in the event, even if highly unlikely, that a patient will code. It is the nature of this discussion which determines what "order" the doctor will write on the chart.