What Does a “Do Not Resuscitate” Notice in a Person’s Home Mean?

Jonathan Davis Jonathan Davis

Occasionally, I see a Massachusetts “DNR Notice” in someone’s home (usually the home of an elderly person).  The notice is formally named a “Comfort Care-Do Not Resuscitate” notice – “CC/DNR” for short.  Recently, I noticed a CC/DNR in an elderly client’s home.  The client said that she didn’t know much about the notice other than: “I guess if they come in and find me dead they won’t do anything to me”.  I said that I didn’t know much more than that about the CC/DNR, but that I’d try to learn more and report back to her.  Here’s what I learned.

A CC/DNR Notice is a Massachusetts state form issued by the Mass. Department of Public Health.  If adopted by an adult individual it must be signed by the individual, his/her guardian (if the individual is legally incompetent), or by his/her Health Care Agent under a Mass. Health Care Proxy.  It also must be countersigned by a physician, nurse practitioner or physician’s assistant.  A copy of the CC/DNR form can be accessed through the hyperlink http://www.mass.gov/eohhs/docs/dph/emergency-services/comfort-care-form.pdf.

If emergency personnel (typically EMTs or other first responders) are called to a residence for a medical emergency they are trained to take a quick look in “the usual” or “likely” places for a CC/DNR or a photocopy of a CC/DNR.  The usual or likely places may be on the refrigerator, on the kitchen or dining room table, on the door to the occupant’s bedroom, on the wall next to the occupant’s bed,  etc.  If they see a signed and countersigned CC/DNR (or a photocopy), and if the CC/DNR does not have an expiration date (most are open ended) they are trained to follow a particular protocol:

  • If the patient is in “full” cardiac or respiratory arrest, they are to not intervene to resuscitate the patient.
    • Here are examples of what the emergency personnel are not supposed to do:
      • CPR
      • Insert an artificial airway
      • Provide additional assistance in breathing (for example, mouth-to-mouth, bag valve mask, positive air pressure)
      • Chest compression
      • “Advanced airway measures”, including intubation
      • Cardiac resuscitation drugs
      • Defibrillation
  • If the patient is not in “full” cardiac or respiratory arrest but his/her heartbeat or breathing is inadequate, the emergency personnel may suction the patient’s airways, administer oxygen, control bleeding, apply a cardiac monitor, try to comfort the patient, initiate an IV line (for possible later use, perhaps at the hospital).  Apparently, if these efforts are insufficient and the patient then goes into “full” cardiac or respiratory arrest (whether in the residence or in the ambulance on the way to the hospital) the emergency personnel are to not increase their intervention beyond what they have already done.
    • COMMENT – The CC/DNR does not seem to permit emergency personnel to “give a try” to more aggressive procedures.
  • If the patient’s “Health Care Agent” under a Health Care Proxy is on the scene or is reached by telephone, and if the Health Care Agent orders the emergency personnel to disregard the CC/DNR, the emergency personnel are supposed to obey the Health Care Agent and not follow the CC/DNR protocol.
    • COMMENT – If the patient is not fully committed to what the CC/DNR requires and if the patient has told his or her Health Care Agent to instruct medical providers to provide more intervention than a CC/DNR permits – then a CC/DNR may not be the right choice for the patient.  Put another way, why have a CC/DNR if the patient wants the Health Care Agent to give emergency personnel instructions that would countermand the CC/DNR?
  • If the patient is not in cardiac or respiratory arrest and his/her heartbeat and breathing are adequate, but he/she has some other emergency (for example, choking on food) the emergency personnel are to help to the full extent of their training and certification.
  • If, despite being in an extreme situation, the “patient” is nevertheless able to tell the emergency personnel to disregard the CC/DNR, they are supposed to disregard it.

The CC/DNR does not bind hospitals or their emergency departments.  These may have their own protocols (which may differ from the protocol for emergency personnel).

*     *     *

Meanwhile, the Massachusetts Dept. of Public Health and various agencies, both governmental and non-governmental, are promoting a relatively new kind of document, called a “Medical Orders for Life Sustaining Treatment” (abbreviated “MOLST”).  This is more complicated than a CC/DNR.  It is a set of standing medical orders by the patient’s medical professional (physician, nurse practitioner or physician’s assistant), binding not only on emergency personnel but, also, on nursing homes and hospitals, with regard to whether or not to perform cardiopulmonary resuscitation, whether or not to ventilate and intubate, and whether or not to transfer to a hospital.  The document also gives the patient the opportunity to express (in writing) “preferences” as to certain other kinds of treatment (more typical of a “living will” or of specific instructions in a Health Care Proxy).

The MOLST requires more patient counseling and education by the patient’s medical professional.  In fact, the MOLST requires the medical professional to confirm in writing that the patient’s choices on the form “accurately reflects” the medical professional’s “discussion” with the patient.

At this point, it is not clear whether, in the future, CC/DNRs will be phased out.  Meanwhile, however, CC/DNRs are still available.

It should be noted that without truly thorough patient education there exists with the MOLST the same risk as exists with the CC/DNR – that the patient will not fully appreciate the reach and implications of the document.  (Witness my client, who didn’t know what her CC/DNR really meant beyond the obvious “if they come in and find me dead they won’t do anything to me”).

Sources on CC/DNR:

Mass. Office of Health and Human Services, Office of Emergency Medical Services – “Comfort Care Frequently Asked Questions”, 2013

Mass. Office of Health and Human Services – “Overview of Comfort Care/DNR Order Verification Protocol”, 4/8/99, updated 1/22/07

Sources on MOLST:

Report and Recommendations of the Massachusetts Expert Panel on End-of-Life Care – “Patient-centered Care and Human Mortality”, Oct. 2010 .   http://www.molst-ma.org/sites/molst-ma.org/files/FINAL-EXPERT-PANEL-REPORT-APPROVED.pdf

Mass. Dept. of Public Health – “MOLST Demonstration Program: Recommendations for Statewide Expansion; Pilot Results 2011”


Dated:  8/13/13

This Article is intended only to provide generalized information.  It is not intended to provide information or advice with respect to specific situations.  To address real life, specific situations you should obtain appropriate professional assistance.

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