Question: My mother is in a nursing home and she has a “non-hospital DNR.” What is that and how does it differ from a traditional DNR?
Answer: The “Do Not Resuscitate” order, or “DNR” came about from a task force commenced by Governor Mario Cuomo in 1985 wherein experts were tasked with reconciling outstanding issues with legally withholding life sustaining treatment. The result was the traditional DNR order which applied to patients in an institution such as hospitals, nursing homes and mental health facilities. Unlike a Living Will which is a general statement of wishes that a person would not want life sustaining treatment administered if there were no hope they would make a meaningful recovery, DNRs are directives which only apply to incidents of cardiac respiratory arrest and prevent the use of cardiopulmonary resuscitation.
The DNR order must be signed by a physician on the Department of Health form and recorded in the patient’s medical record. It can be signed by the patient herself, or if she lacks mental capacity, the DNR can be signed by a family member or health care agent. The DNR order must be reviewed periodically by a physician. This means they should be re-visited every seven days for hospital patients and at each visit for outpatients, but at least every 60 days for nursing home residents.
Due to the fact that the traditional DNR can only be used in an institutional setting, in 1991 the legislature expanded the Public Health Law to include a non-hospital DNR order. This would cover the prevention of cardiopulmonary resuscitation in emergency situations outside of a facility. The non-hospital DNR would be utilized for emergency services personnel, including first responders and emergency medical technicians, when the patient is at home or in another community setting. While EMS workers are legally obligated to honor the non-hospital DNR, they may still administer CPR if 1.) they reasonably believe in good faith that the consent is not valid and 2.) if family members or others at the scene object to the order and physical confrontation appears likely.
Doctors in the emergency room of a hospital have more discretion in that they can refuse to honor a non-hospital DNR for the same reasons as EMS personnel and if other significant and exceptional medical circumstances warrant doing so.
Non-hospital DNR orders must be treated as any other DNR order if the patient is admitted to a hospital. It will remain effective in the hospital until the order is revoked or a doctor cancels the order. Like a traditional DNR, a non-hospital DNR must be in writing on the standard form from the Department of Health. The form must be reviewed by a physician at each visit, but at least every 90 days, but review need not occur more than once every seven days.