Do Not Resuscitate Orders
A DNR (Do Not Resuscitate) Order is a doctor's order initiated at the request of the patient who wishes not to be revived should the patient stop breathing or should his or her heart stop beating.
When a person is in a hospital, nursing home or a place where there is a relationship of some duration, health care decisions such as those about Cardiopulmonary Resuscitation (CPR) can be expressed in documents such as living wills or other advance directives.
In pre-hospital situations, such as in an ambulance, the relationship is brief and usually emergent. If a person wishes to notify emergency medical personnel that he or she wants only limited care, an advance directive or living will cannot be used. Instead, a patient must have his or her doctor assist with completing the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form. There is a specially numbered wristband that indicates the patient's wishes. The patient may wear the bracelet or have it available in a highly visible place like the refrigerator door. (A metal bracelet or necklace may be purchased as well.)
The MOLST Order and bracelet notify emergency medical personnel that the patient wishes to have only certain types of medical care and that he or she does not wish to be resuscitated in the event of cardiac or respiratory arrest.
If a person wishes to have a DNR status and expresses such in an advance directive, he or she should also have a doctor complete an EMS/DNR Order form and wear the DNR bracelet, as ambulance staff are not able to follow an advance directive.
Maximal (Restorative) Care Before Arrest, Then DNR
In this option, one requests the full scope of restorative care before the heart stops or before breathing stops. This may include:
- Cardiac monitoring
- Drug therapy
If at any time during treatment the patient's heart or breathing stops, the patient will not be resuscitated; that is, personnel will not provide CPR, cardiac pacing, defibrillation or drug therapy.
Limited (Palliative) Care Only Before Arrest, Then DNR
In this option, treatment given by emergency medical personnel may include:
- Opening the airway by non-invasive means
- Passive oxygen
- Controlling external bleeding
- Positioning for comfort
- Splinting, if necessary
- Transportation to hospital or designated facility capable of providing in-patient hospice care
If at any time the person's heart or breathing stops, the emergency medical personnel will not provide CPR, cardiac pacing, defibrillation or drug therapy.
Completing the Order Form
All physicians, hospitals, nursing homes, hospice programs, local health departments and home health agencies should have MOLST forms (PDF) available at your request. If your physician does not have the properly numbered forms, he or she can obtain free copies from the Program Development Office of the Maryland Institute for Emergency Medical Services Systems (MIEMSS) by calling 410-706-4367.
Remember to place the completed Order form in a visible area such as on the refrigerator. If the person does not wish to wear the bracelet, it is helpful to keep it handy (near the bedside, purse, or the like).
Reciprocity with Other States
Some states may not recognize Maryland's MOLST Order. If you or your loved one want a DNR status and he or she expects to spend a significant amount of time in another state, it would be a good idea to complete that state's MOLST Order form as well.
Revoking the MOLST Order
The MOLST Order may be revoked at any time. To revoke it, merely destroy the bracelet, metal emblem and the Order form. It can be re-instituted, if desired, by completing the application again.
If the patient is being evaluated by emergency medical personnel and decides at that time that he or she does want CPR and other treatment in the event of cardiac or respiratory arrest, the patient needs only to state that verbally. The emergency medical personnel will follow the verbal request and ignore the written Order and the bracelet/emblem. The patient's oral statement must be made directly to the EMS personnel.
No other person (even a legally authorized decision maker) can verbally revoke a MOLST Order.
Discussing your Options
This is not a decision to make lightly. A person considering the DNR status should speak with a trusted physician and family members so all understand the individual's wishes.