Understanding DNR Codes And Levels Of Care Before They Are Needed

Senior DNR Codes

Seniors and DNR codes

Many caregivers at some point or another, will have to answer the question “Does your loved one have a DNR?”
More often than not that question will arise at a stressful moment like a medical emergency.

DNR (Do Not Resuscitate), often known as “no code,” is an advance directive document which guides medical staff to NOT perform CPR or otherwise try to revive your loved one if their heart stops.

If your senior loved one does not have a DNR in place, then they are thought to be a “full code” and will receive all aggressive revival measures in the case that their heart or breathing stops.

As the caregiver, you should be able to recall their code status during an emergency – full or no code or somewhere in between.

A DNR advance directive is applied only when the senior is unable to express their own wishes and needs to someone else. If they do not have the DNR advance directive they will be requested to direct their care themselves and in a moment of emergency that is usually easier said than done.

What to know about DNR orders

A doctor has to sign a DNR advance directive for it to be placed in your senior’s medical record. This is in contrast to a ‘living will’ that needs a signature of the person associated and probably a witness.

A new DNR is needed for each hospital admission that includes transfers between facilities.

Many EMS (emergency medical personnel) professionals do not have permission to honor a DNR order except specific to the state they reside in and only if it is properly executed. For instance, some states have one DNR document for use by EMS technicians and anothers for the hospital. A Physician Order for Life-Sustaining Treatment (POLST) that covers out of hospital DNR orders, may be obtainable in your state. Also there are bracelets or documents that can be placed on the refrigerator to inform first responders or your loved one’s wishes.

A lot of people have also created advance directives that can state the type of care they want at the end of life.

The number of seniors who have prepared advance directives, especially a DNR order, is growing but sadly, many have not expressed their wishes which leaves family caregivers with difficult decisions at difficult times.

What a DNR Expresses

Simply put, a DNR informs the medical staff that your senior loved one wishes to die naturally with no heroic measures of ventilation, intubation, or vasopressor support.

A DNR DOES NOT imply “Do Not Treat” if a condition occurs that could benefit from treatments like IV fluids, antibiotics or oxygen.

Though age should not be a decisive factor to make a decision for a DNR order, for many seniors, especially those who are already weak, performing CPR can be useless. CPR may be effective but vulnerable heart and lungs will probably have repeated failure in the process. Not only would it not extend their life, it could be harmful to a seniors body.

CPR can lead to painful injuries or a loss of functional status. It is not uncommon for a senior’s ribs to be broken causing harm to internal organs at the time of chest compressions. It can also result in adverse outcomes like hypoxic brain damage and increased physical disability.

The Different Types and Levels of DNR Orders

There are different levels of medical intervention depending on the policy of the specific hospital or nursing home. It might be wise to ask the facility for their policy related to different levels of DNR care to help you understand the process before you or your loved one needs it.

Some facilities use the following terms to express how they handle DNR levels like:

  • Comfort Care – In the case a person’s heart stops beating, only ‘comfort’ will be given to the patient.
  • Comfort Care Arrest – May apply life-saving measures before the heart stops beating however that resorts to ‘comfort’ measures once it stops.
  • Specified – These are written by a doctor, and describes which methods can or cannot be used, such as “Do not intubate but can do chest compressions.”

Other facilities, particularly long lasting care facilities can define various levels of treatment in case a medical emergency happens. These are example levels that you might find in a senior care facility:

  • Level 1:  Stay in the facility and make sure you’re comfortable, however not given antibiotics or other medications to cure you.
  • Level 2:  Stay in the facility and get all medications and treatments possible inside the facility.
  • Level 3:  Be transferred to a hospital from a nursing facility but not applied CPR or taken to intensive care.
  • Level 4:  Be taken to a hospital and provided all possible medical interventions. Essentially, do all that is possible.

Level 1 and 2 allow seniors to pass naturally and in familiar (more comfortable) surroundings.

Some states may have terms like the following:

  • AND: Allow natural death, used in end of life circumstances to be clear that an end is expected and the natural consequences of the situation are allowed to proceed.
  • DNAR: Do not try resuscitation. This should be accompanied by specifics of which types of interventions can or can not be used if the heart stops beating.

Executing Advance Directives

Hopefully having gone through this article you will realize that these documents should be carried out and a healthcare power of attorney appointed long before they are needed.

During a medical emergency our seniors may not be able to express their wishes to the healthcare staff or family members and a recognized healthcare power of attorney can execute these decisions on a senior’s behalf following their advance directives.

It is wise to be sure that a power of attorney has been told about wishes and possesses a copy of the advance directives.

All family members should be aware of who the power of attorney is to avoid confusion when the time arises and expedited decisions are needed.

Keep in mind that the senior’s advance directives can be modified any time.

If you are an senior caretaker or a family caregiver of an older parent, it can be a sad and uneasy topic to talk about with loved ones.  Just remember, dying with dignity can be attained when our healthcare desires are expressed and you should be prepared for whatever your senior loved ones decide.

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