All healthcare professionals and many patients and their families know what DNR means. The Do Not Resuscitate order (also known as No Code) means no CPR and no call to the Code Blue Team when respiration and/or heart beat stops. However, in the last few years a new abbreviation, DNAR has become commonplace. DNAR is Do Not Attempt Resuscitation.
How is DNAR different from DNR? DNAR reduces the implication that resuscitation is likely and creates a better emotional environment to explain what the order means. Since we know that resuscitation attempts are often unsuccessful, especially in those with advanced cancers, the DNAR order gives a more realistic picture.
The American Heart Association adopted this language for resuscitation orders in 2005. For example, a conversation with a daughter about her father might be “Do you want us to attempt to resuscitate your father if his heart stops?” rather than “Do you want us to resuscitate your father?” Of course, in both DNAR and DNR, further discussion needs to happen to address treatments beyond CPR.
Some patients and families have the misconception that the DNR/DNAR orders will mean less care and fewer interventions beyond not doing CPR and calling a code; that it is a kind of giving up or even abandoning. Even some healthcare professionals view the No Code order as meaning that all aggressive treatments have stopped. I have often seen healthcare professionals questioning why we are still doing dialysis or antibiotics when there is a DNAR order. The DNR/DNAR order is only part of the conversation and only refers to cardiopulmonary resuscitation.
Then we have the AND order. It stands for “Allow Natural Death.” This is growing in acceptance around the country to replace DNAR or in addition to it. The original idea for AND came from ethicist Chuck Meyers in 2000. Meyers believed that the terminology of AND recognized the person was dying and ensured the family that comfort measures were being provided.
AND orders emphasize the plan to allow natural consequences of a disease or injury, and stress the need for ongoing end-of-life care. Clearer language affirms that the patient wants nature to take its course without CPR, and what is wanted is comfort. Some may view the DNR/DNAR order as more about what won’t be done for the patient. An AND order is usually interpreted as more humanistic, with the focus on what will be done for the patient. Generally the AND order implies more conversation has occurred beyond CPR preferences.
Finally, the CMO order. CMO stands for "Comfort Measures Only." Some facilities’ policies accept this order in place of, or in addition to, DNR or DNAR order to provide a clear treatment plan.
Whatever your facility uses, the important thing is that there be clear communication about options, patient goals and wishes, and the treatment plan to accomplish this.
What does your facility do? How helpful do you think these terms are?