How is an Out-Of-Hospital DNR Different from a Directive to Physicians?

A directive to physicians, also known as a living Will, is a document that allows you specify what kind of life-sustaining treatment should be administered or withheld if you are diagnosed with an irreversible or terminal condition.

The fact that the word “directive” is included in the document scares a lot of clients because they understand it to be a command or mandate. They fear that if they sign such a document, a doctor may refuse to treat them if they are diagnosed with a terminal condition, or may refuse input from loved ones regarding when life-sustaining treatment should be withheld.

In actuality, the document is just a way to share your healthcare wishes and explain your reasoning in order to relieve your loved ones of a lot of stress they may feel in making these decisions without your guidance. Some clients who are physicians assure me that no doctor would ignore the wishes of typically the patient’s most emotional relative despite a signed directive to physicians for fear of legal repercussions.

In contrast, an out-of-hospital Do Not Resuscitate Order (OOH DNR) is a legally binding document prepared and signed by a patient’s attending physician that directs health care professionals in an out-of-hospital setting not to initiate or continue life-sustaining treatment such as:

• cardiopulmonary resuscitation
• advanced airway management
• artificial ventilation
• defibrillation
• transcutaneous cardiac pacing

Any competent person can execute an OOH DNR at any time directing health care professionals acting in an out-of-hospital setting to withhold life sustaining treatment. An out-of-hospital setting can include places like a long-term care facility, a private home, a hospital emergency department, a physicians office, or a vehicle.

Because signing such a document has huge implications, the the document must be signed by the patient not only in the presence of two witnesses, who also sign the document, but also signed by the attending physician, who would then note the existence of the order in the patient’s medical record and the reasons such an order has been executed.

There is also a procedure for issuing an OOH DNR order for a person who is incompetent, in reliance of a previously signed directive to physicians. In such a situation, an attending physician and the patient’s legal guardian, proxy, or agent under a medical power of attorney may execute an OOH DNR order on behalf of the patient.

The OOH DNR is effective once it is executed.

It’s important to note that the desire of a competent person supersedes the effect of an out-of-hospital DNR order. A person can revoke the OOH DNR order at any time by destroying the order or by communicating the patient’s desire to revoke the order to health care professionals.

In other words, if you are in a life-threatening situation and you are calling out for help and treatment, healthcare professionals would not stand around and watch you die despite the existence of such a document.

While I routinely prepare directive to physicians for clients, there are only a handful of times when I have prepared an OOH DNR. Those rare situations involved clients who had been terminally ill for an extended period of time and were just tired of fighting. In most cases, those who are healthy would want treatment in the event of an emergency and would not want to execute an OOH DNR.