By Dr. Ferdinando Mirarchi, DO -- Board-Certified Emergency Physician, Founder of MIDEO Health
Legally, "it depends." A DNR is a physician's order. That means only a physician or an approved medical provider has both the medical and legal authority to rescind it. Family members can influence the decision but don't have the authority to erase that decision because they disagree with it.
I hear often that "the family reversed the DNR." Let's address some misconceptions and how the DNR may get overridden.
First, we need to answer, "what is a DNR order?"
When you hear that a DNR got overridden, it probably wasn't a DNR in the first place. Most likely, it was a living will or advance directive that was misinterpreted as a DNR order.
In a scenario where a DNR did already exist and was overturned, it is not because the family reversed it. While a family can influence, the actual decision to reverse the DNR order comes from a physician or medical provider approved to do so.
The DNR Decision Tree
The more pressing issue is why the family or the appointed agent chose to influence the decision.
The DNR decision tree:
- If the patient actually did want and had a physician create a DNR order with informed decision making, then the ethical standing behind the decision should be that no one can overturn the DNR.
- There are situations where it is appropriate to suspend or even terminate the existing DNR order:
- For example, a surgery. Many healthcare institutions have policies to reverse a DNR order for the surgery and for a period after the surgery to allow for aggressive care and treatment.
- There are situations where it is appropriate to suspend or even terminate the existing DNR order:
- How an appointed Health Care Agent (HCA) can override a DNR order
- When you appoint a HCA you give this person permissions legally to influence and consent to the creation of a DNR order as well as the rescinding of a DNR order.
- Ethically, the HCA should be acting in accordance with your values and preferences. However, they might end up following their own beliefs and values.
An Example of an Overridden DNR
There are common scenarios of conflict that occur with DNR orders, and it does happen often.
There was one time in particular that I remember when I was working in the emergency department.
The patient arrived unconscious. Our team immediately saw the DNR in the chart. His son was with him, and he had just flown in from the Midwest a few days prior. He immediately makes it clear to everyone that his father didn't understand what he was signing and signed it while he was extremely sick, but has since been feeling better.
At this point, our team had about 30 seconds to figure this all out. Remember, the patient is unconscious in the emergency room. He is our responsibility. The room is no longer focused on what the patient documented and the son, while his intentions were good, is trying to impose his will over the process. There is no time to investigate whether the son's claim is true. The patient's heart could have stopped at any moment. Someone has to decide whether to begin CPR right at that moment. We erred on the side of saving the patient.
The DNR Decision
Now here is the part nobody explains to patients, and it is the reason I am writing this.
We performed CPR on the patient. The reality is we were not sure whether he really wanted it or not. All we knew was there was a signed DNR order in the chart.
If I honor the DNR and the objecting son decides I killed his father, I may spend the next two years in depositions defending a decision I made. But another reality exists where if I save his life with CPR, I may also get sued. In fact, over my 25 year career in emergency medicine, I've seen that in the last 10 years a huge increase in lawsuit payouts related to saving a patient's life.
I want to make it perfectly clear that the people I have worked alongside have always tried to do right by patients under conditions that make it nearly impossible.
The fact is that many hospitals and physicians have focused on saving lives first as you can't bring people back from the dead. This is what we have also called defensive medicine and it makes sense as you can always pull a tube or shut off a machine, but you cannot bring someone back from the dead. But to be clear, some defensive medicine practices are now being challenged in the courts under "wrongful continuation of life" cases.
A DNR Is Not an Advance Directive
It's important to know that a DNR and an advance directive aren't the same thing.
A DNR is a medical order that is very narrow in scope. However, it is very broad in how it is applied. A DNR order applies only in a specific event. For example, if your heart stops, do not attempt to restart it with chest compressions (CPR).
That is it. It says nothing about antibiotics, surgery, a ventilator, a blood transfusion, or whether you should be treated aggressively for pneumonia you would almost certainly survive.
Unfortunately, the DNR order is often applied more broadly. In my published TRIAD Patient Safety research on how clinicians interpret these documents, I found that physicians and nurses routinely see a DNR and treat the patient as though they had asked for comfort care only. So, the patient can be critically ill and saved but is left to die due to the understanding of the DNR order.
This is a mistake that I have seen many physicians and other medical providers make. It is also the one I have spent much of my career studying.
Patients who were not dying and had years in front of them were managed as if they were at the end of life because someone glanced at 3 letters (DNR) and filled in the rest with their own preconceived notions of what they think should be done.
My TRIAD research documented this extensively. In one nationwide multicenter study, 64% of the physicians, 80% of nurses and 90% of paramedics surveyed interpreted DNR as comfort care or end-of-life care extending beyond the cardiac arrest itself.
A DNR document can't answer a follow-up question or clarify what type of care you want outside of a cardiac arrest. The document is trying to do what it is designed to do, but it just isn't enough.
In fact, that is why I do not believe a signature on a piece of paper is enough. When the patient's voice is absent, someone else's voice will fill the space.
You Need a MIDEO Advance Directive to Pair with Your DNR
I'm completely honest when I say that a DNR form is not enough. You need a video advance directive that explains exactly what you want in less than 30 seconds. A video of you speaking takes away all of the doubt and second guessing.
When there is a video, the son who is arguing is less impactful and the physician can act in accordance with what your wishes are because they are now known. Now the physician can show the son that his father was awake and mentally competent while making his decision. He can watch his father sit up straight, look into a camera, and say what he wants and why he wants it. I have seen and experienced a video advance directive stop an argument in seconds.
And it changes something for the clinicians as well, which I think matters more than people realize. When I see the patient speaking in his own words and emotions, I know what I am doing is correct. It is reassuring for me that I made the right decision, and it's also defensible.
That is why I built MIDEO. I wanted to put the patient back in charge in that room, even when they can't speak for themselves.
That does not make the grief disappear, and from my experience, it certainly doesn't guarantee that every relative will agree. But it changes the argument. The family can no longer as easily claim that the patient misunderstood, never discussed it, or would obviously want something different now.
The video protects the patient by making their voice harder to erase. It protects the clinician by making the patient's intent easier to understand, document, and defend.
If you have a DNR, or you are thinking about one, my advice is to make sure all of your documents and wishes are in the same quickly retrievable place with MIDEO.
We can walk you through it. Give us a call or reach out online.
-- Dr. Mirarchi, Board-Certified Emergency Medicine Physician and Founder of MIDEO Health
