Running Head: NURSING ISSUES RELATING TO DNR ORDERS

Nursing Issues Relating to DNR Orders

Ihilani Lum
Kapiolani Community College

NURSING ISSUES RELATING TO DNR ORDERS

Nursing Issues Relating to DNR Orders

Do-not-resuscitate (DNR) orders are written orders by a physicians stating that
the patient will not receive treatment efforts to keep the patient alive if something life
threatening should happen. These treatments include intubation, ventilation, vasopressor
support, or cardiopulmonary resuscitation (CPR) (Tsang, 2010). DNR orders are there to
support the patients autonomy and to prevent non-beneficial interventions (Yuen, Reid,
& Fretter, 2011). DNR orders are often poorly communicated and therefore, should be
presented clearer to nurses, patients, family members, and surrogate decision makers to
provide quality end-of-life care for the patient. Some problems are that patients and
family members dont fully understand DNR orders, nurses provide inadequate care for
patients due to lack of communication, and that DNR orders are not fully clarified on
what it means and what type of care should be provided.
Patient focus
The majority of patients are poorly informed about what are DNR orders and
what do they mean (Yuen et al., 2011). Some patients and family members think that
DNR stands for Do Not Treat and therefore are hesitate to agree with the order. The
patient and family assume that with DNR orders, the patient will not receive oxygen, IV,
or antibiotics if needed (Tsang, 2010). Patient and families also misunderstand that CPR
will keep patients alive and living as they were before (Breault, 2011). Patients are also
mislead by mass media into thinking that survival rates of CPR are close to 50% but in
reality its 10-15% (Yuen et al., 2011). Not only are the patients ill informed about DNR,
surrogate decision makers are also ill informed which leads to more problems for the
patient.

NURSING ISSUES RELATING TO DNR ORDERS

Problem when Surrogates make the Decisions

Surrogate decision makers are people who decide whether or not the patient
should receive a DNR order because the patient can no longer make that decision on his
or her own. Surrogates are involved in most of DNR discussions for older adults. This
process takes a lot longer because the surrogate requires more information, thus needing
more than one meeting with the physician. Surrogates also encounter ethical and
emotional complexities when deciding on whether or not the patient should receive DNR
orders. The surrogates feel guilty because they think they are making a death sentence
for the patient. Since this process is lengthier, there is a shorter period between DNR
orders and death than if the patient made the decisions by themselves (Torke et al., 2011).
While the surrogates are deciding, the patient and healthcare providers are in limbo not
sure if the patient is a full code or has a DNR order. This affects the quality of care for
the patient because nurses are unsure the type of care to provide the patient.
How the Issue Affects the Nursing Field
When the orders are not fully explained or if the nurses dont follow the DNR
order correctly the patient doesnt receive the highest of quality nursing care possible.
Lack of communication can leave a nurse in a dilemma when a patient undergoes cardiac
arrest. An example is if the patient has a DNR but otherwise everything else done
order. This order is very unclear as what to the nurse specifically needs to do and which
procedure to follow (Tsang, 2010). When DNR orders are not clear, this causes confusion
that remains problematic in clinical practice (Chen et al., 2014). According to Tsang
(2010), DNR orders change the nursing attitudes/care for the patients. They think that
DNR orders automatically mean palliation care. A study showed that when nurses see

NURSING ISSUES RELATING TO DNR ORDERS

DNR orders, they are less likely to perform a variety of physiologic monitoring
techniques, do simple massages, and report the patients condition. Because of this
assumption, patients are at the risk for being medically and psychologically abandoned
(Chen et al, 2014). According to Tsang (2010), some senior physicians suggest that the
DNR orders shouldnt be written down to prevent neglect and assumptions from the
nurses. From this action, patients receive the appropriate care from nurses until
something life threatening happens. When the patient undergoes cardiac arrest, the full
code is cancelled last minute to preserve the patients wishes. According to Yuen (2011),
majority of the DNR orders that were in their study were written 2-3 days before the
patients death.
Solutions to Clarify DNR orders
A physician, Breault, noticed that healthcare providers, patients, and family
members all misunderstood what DNR orders are on a certain level. Because of this he
suggested that the name DNR changes to either do not attempt resuscitation (DNAR) or
allow natural death (AND). He believes that changing the name and explaining what it
means will clarify a lot for everyone (Breault, 2011).
Detailed DNR orders
Besides changing the name of DNR orders, another solution to clear up the
confusion is be more specific. Ohio department of health adopted a law in 1998, which
split DNR into two orders that were more specific. One is DNR Comfort Care
(DNRCC), which states that the patient only receives comfort care. The other one DNR
Comfort Care-Arrest (DNRCC-Arrest), which states that the patient receives aggressive
interventions until cardiac or respiratory arrest. After adopting these two DNR orders,

NURSING ISSUES RELATING TO DNR ORDERS

patient care improved because nurses and healthcare providers knew specifically what
kind of care to provide (Chen et al., 2014).
Conclusion
Overall DNR orders are too vague for the patients point of views and health
providers point of views. Patients dont understand what DNR orders are and nurses
question the type of care they should provide. With everyone not fully understanding the
order, the patient loose out on the appropriate care that they should receive. DNR orders
are all about respecting the patients autonomy and if the orders arent clear for the nurses
then the patients autonomy is at risk of being violated. Clarifying what DNR orders are
and what specifically needs to be done is what is essential in order for the patient to have
quality care provided.

NURSING ISSUES RELATING TO DNR ORDERS

Reference:
Breault, J. L. (2011). DNR, DNAR, or AND? Is Language Important? The Ochsner
Journal, 11(4), 302306.
Chen, Y.-Y., Gordon, N. H., Connors, A. F., Garland, A., Chang, S.-C., & Youngner, S. J.
(2014). Two distinct Do-Not-Resuscitate protocols leaving less to the
imagination: an observational study using propensity score matching. BMC
Medicine, 12, 146. doi:10.1186/s12916-014-0146-x
Torke, A. M., Sachs, G. A., Helft, P. R., Petronio, S., Purnell, C., Hui, S., & Callahan, C.
M. (2011). Timing of Do-Not-Resuscitate Orders for Hospitalized Older Adults
Who Require a Surrogate Decision-Maker. Journal of the American Geriatrics
Society, 59(7), 13261331. doi:10.1111/j.1532-5415.2011.03480.x
Tsang, J. Y. C. (2010). The DNR Order: What Does it Mean? Clinical Medicine Insights.
Circulatory, Respiratory and Pulmonary Medicine, 4, 1523.
Yuen, J. K., Reid, M. C., & Fetters, M. D. (2011). Hospital Do-Not-Resuscitate Orders:
Why They Have Failed and How to Fix Them. Journal of General Internal
Medicine, 26(7), 791797. doi:10.1007/s11606-011-1632-x

NURSING ISSUES RELATING TO DNR ORDERS

Score __________ _ Percentage __________________

A total score of (75%) or higher is required to pass. Late papers will receive a "0"

The score will be converted into a percentage 25 points = 100%

Dimension
Topic 3
Research
(20%)

Choice of topic
Scholarly sources
Recent scholarly
sources
Use of sources

Subject
Matter
(30%)
15

Content

Support
15
Organiza Structure
tion (25%)
9
Transitions from
one idea to the
next
7
Introduction and
conclusion

Exceeds Expectations
Very original topic
Sufficient, relevant
sources At least 2 from
nursing journals
Recent, appropriate
sources

Needs Improvement

Approved topic
Not appropriate for paper
2 sufficient sources; some few or no scholarly
irrelevant
sources
Recent but some
inappropriate sources;
none within last 2 yrs.

none within last 5 years

data and arguments from Statements are factually

sources are appropriately accurate but irrelevant to
used
the topic.
Sources are over used
Comprehensive and
Most statements are
accurate; key elements of accurate; missing one of
assignment covered
the key elements of the
assignment.
Major points supported statements are adequately
by specific examples and supported. Minor opinion
references
statements

misrepresents some
sources' data or
conclusions. Sources
are over used.
generalized statements
Not all areas are covered

Excellent section
transitions

adequate section
transitions

lack of section transitions

clear and concise intro

and conclusion
Introduction slightly weak
or conclusion does not
match the topic

no clear intro and/or

conclusion. The
introduction does not
follow topic directions

A few errors, minimal

distraction

Many errors. Mechanics

interfere with reader's
understanding of text

Paraphrased: the other

source is identifiable as
the origin of the style and
structure. No individual
thoughts. Citations are
lacking

close paraphrase:
presentation of the
information is clearly the
work of someone else.
Lacking citations. This is
unacceptable.

few errors in formatting

cover page, headers, intext citation, and/or
reference page

cover page, headers, intext citation, reference

page formatted
incorrectly

Statements are made

without providing
support. Many opinions
stated
Entire paper is very clear paper is clear and
entire paper lacks clarity
and organized
organized for the most part and structure

Introduction provides
sufficient background on
the topic and conclusion
follow logically from the
body of the paper.
Follows directions for
paper
9
Mechani Sentence structure Excellent mechanics
grammar, spelling,
cs (22%)
sentence structure,
abbreviations
Run on sentences
7
Paraphrasing
Not paraphrased!
Sources are
mined for facts but the
student
provides style and
structure
8
Use of APA format
Line spacing

Meets Expectations

cover page, headers,

running head,
subheaders, in-text
citation, reference page
correctly formatted

TOTAL

Comments

NURSING ISSUES RELATING TO DNR ORDERS

1/5/15/pt

Check off List

_____ Title page including Running head correctly formulated
_____ Title on first page of body of paper
_____ Compose a First paragraph that indicates what will be discussed, and in what
order.
_____ Correct citations for all ideas that are not your own
_____ Correct form of citation using APA use the APA book
_____ Double spacing exactly throughout entire paper
_____ Spelling
_____ Punctuation: commas, semicolon, colons
_____ Page numbers
_____ Conclusion paragraph
_____ Check for opinion words, (such as fortunately, should, personally, I
think/believe/suppose, I am of mixed opinions about / on, this it seems to me that)
_____ Fonts all fonts are the same size and type.
_____ Reference page APA, hanging indents, less than 5 years old
_____ Follows rubric for all requirements of paper
_____ Rubric pasted at end of paper
_____ Check off list pasted after the rubric.
_____ Sent to Brainfuse for review