19 Apr 2022
DNR (Do Not Resuscitate) is an order with writing instructions from a physician telling health care workers not to execute Cardiopulmonary Resuscitation (CPR). The CPR could be mouth to mouth or machine breathing and chest compressions to re-establish the function of the heart and lungs when someone’s heart or breathing is not working. When there is no DNR order, health care providers will use CPR in an emergency, but why do some people do not want the CPR? A convalescent may not want CPR attempted when:
- He/she has a terminal illness or has several health problems, and there is no medical advantage expected;
- The patient could survive with the CPR, but the quality of life would suffer. For example, survive but permanently be connected to a machine to breathe; and
- Decease is expected soon, and the patient does not want an aggressive intervention, and he/she prefers a natural passive death.
It can be distinguished between pre-hospital and hospital DNR. The first one is a DNR form that can be used outside of a hospital by emergency medical personnel or in assisted living. The second one is a DNR form used in hospitals, and the medical healthcare will know how to act in an emergency.
The DNR order works differently according to the country, and in this article, we will talk about the DNR order in the United Arab Emirates, United Kingdom, France, and Spain.
The United Arab Emirates
The Federal Law Number 10 of 2008, amended by the Federal Law Number 4 of 2016 on medical liability, introduces new provisions about the DNR that is also known as a natural death. According to article 11, natural death may be allowed by not doing cardiopulmonary resuscitation to the dying patient, if:
i. The patient is suffering from a chronic disease;
ii. All available medications methods are used;
iii. The doctors claim that medication is useless in the patient’ case;
iv. It is advised by the attending physician not to do the cardiopulmonary resuscitation; and
v. Three consultant physicians at least decide that the patient’s interest requires allowing a natural death and not conducting cardiopulmonary resuscitation.
However, at the express request of the patient, resuscitation cannot be prevented even if resuscitation is useless. Following the above provision won’t be considered medical negligence.
United Kingdom
As per the British Medical Association and the Royal College of Nursing, the DNR order must only be provided after discussion with the patient or his/her family. Furthermore, the UK medical profession has quite extensive guidelines for situations in which DNR may be issued:
i. If a patient’s condition is such that revival is unlikely to prosper;
ii. If a mentally competent patient has constantly stated or recorded the fact that he/ she does not want to be resuscitated;
iii. If there is a progressive notice or a living motivation that says the patient does not want to be resuscitated; and
iv. If resuscitation is not successful, it would not be in the patient’s best interest because it would reduce the patient’s quality of life.
United Kingdom is part of the European Convention of Human Rights (ECHR). Article 8 mentions that everyone has the right to handle their medical treatment, and clinicians are under a lawful obligation to guarantee this happens. The UCHR applies in public health care bodies in the UB under section 6 of the Human Rights Act (1998).
France
Advance directives make it possible to let the doctor know your wishes and enforce if one day you are no longer able to express it. According to article 37-1 of the public health code, in the event of refusal to apply advance directives such as the DNR, the decision is justified. The testimonies and opinions collected and the reasons for the decision are entered in the patient’s file. The person of trust, or, failing that, the family of one of the patient’s relatives, is informed of the decision to refuse to apply the advance directives. The Leonetti law of April 22, 2005, relates to the rights of sick and dying people. It prohibits therapeutic relentlessness, that is to say, any treatment intended to prolong a person’s life at the end of life. The doctors are authorized to limit or stop the treatment to allow the patient to die relieved and accompanied. Thus, palliative care must be administered to him to alleviate his suffering.
The Law of April 22, 2005, was considered insufficient, hence the birth of the new law of February 2, 2016, known as the Claeys-Léonetti law. This law specifies the advance directives in the article L.1111-11 of the Code of public health(France): any adult can write them; they express the will of the person relating to his end of life about the conditions for continuing, limiting, stopping or refusing treatment or medical procedures; Revisable and revocable at any time and by any means, they can be drawn up following a model, the content of which is set by decree in the Council of State taken after the opinion of the High Authority of Health and which provides for the situation of the person according to knows whether or not she/he has a severe medical condition at the time of writing them.
Spain
In Spain, there was no law regulating advance directives during the 1990s. In 2002, it was approved the Patient Autonomy Law. The article held for the first time the advance directives and recognized the right to designate a representative to serve as interlocutor with the doctor or the health team, if necessary. Through the DNR order in Spain, a person of legal age, capable and free, expresses his will in advance, so that it is fulfilled at the moment in which he reaches situations in which circumstances he/she is not able to express them personally, about the care and the treatment of his health or, after death, of the fate of his body or its organs. The grantor of the document may also designate a representative to serve as their interlocutor with the doctor or healthcare team to ensure compliance with the previous instructions.