A Do Not Resuscitate (DNR) order instructs health care providers not to perform CPR if a patient stops breathing or their heart stops beating. Regulations around who can sign a DNR order vary by state, but in most cases a licensed clinician must authorize the order based on a patient’s informed preferences, medical condition, and overall prognosis. This article explains who can sign a DNR, how it is documented, and common questions to help patients, families, and clinicians navigate the process.
What Is A DNR And Why It Matters
A DNR is a medical order placed in a patient’s chart indicating that CPR should not be attempted in the event of cardiac or respiratory arrest. It is distinct from other advance directives, such as living wills or medical powers of attorney, which outline preferences for a variety of treatments. A DNR focuses specifically on resuscitation efforts in emergencies and is intended to prevent invasive procedures that may not align with the patient’s goals or quality of life.
Who Can Sign A DNR Order In The United States
In the United States, the authority to sign a DNR order generally rests with a licensed clinician who can assess a patient’s medical status and discuss goals of care with the patient or their authorized representative. This typically includes:
- Physicians (MDs or DOs)
- Advanced practice clinicians such as Nurse Practitioners (NPs) or Physician Assistants (PAs) in many settings
- In some states, certified or designated clinicians with appropriate training can sign DNR orders
Important nuances:
- In acute hospital settings, a DNR order is usually signed by a physician who can document the rationale and ensure alignment with the patient’s goals.
- In long-term care facilities or home health contexts, NPs or PAs may have authority to sign, depending on state law and facility policy.
- Some states require a formal process where a patient or their legally authorized representative must provide informed consent, express preferences, or sign a specific form in addition to the clinician’s order.
How A DNR Is Documented Across Settings
The documentation pathway for a DNR order varies by setting but generally follows a consistent pattern designed to ensure clarity in emergencies:
- Hospital inpatient: A physician typically drafts the DNR order in the medical record, often accompanied by a Do Not Resuscitate form or electronic order that is clearly visible in the chart.
- Emergency department: DNR status is reviewed upon arrival and updated as needed to reflect current patient preferences and clinical status.
- Nursing homes and long-term care: DNR orders are documented in the patient’s chart and may be part of a standard admission package or annual care planning process.
- Home and hospice: DNR orders are coordinated with the patient’s primary clinician and hospice team, ensuring that home-based resuscitation preferences are respected.
In all cases, the DNR order should specify the scope, such as whether it applies to full CPR or less invasive resuscitation attempts. It should also note any limitations or conditional statements based on the patient’s status or prognosis.
Informed Consent And Alignment With Patient Goals
A valid DNR order requires informed consent. Clinicians should discuss the following with the patient or legally authorized representative:
- The likelihood of success and potential harms of CPR in the patient’s specific condition
- Alternatives to CPR, such as comfort-focused care or palliative measures
- How a DNR interacts with other existing advance directives
- How the DNR will be implemented if the patient’s condition changes
Documentation should reflect the patient’s values and medical goals. When a patient lacks decision-making capacity, a legally authorized surrogate or power of attorney can participate in the discussion and sign the DNR order if state law permits.
Common Myths And Clarifications
Understanding the true scope of a DNR can prevent misunderstandings:
- Myth: A DNR means no care at all. Clarification: A DNR only affects resuscitation efforts. Other treatments and comfort measures can continue.
- Myth: A DNR is permanent. Clarification: DNR status can be reviewed and updated as goals, health status, or prognosis change.
- Myth: Only doctors can sign a DNR. Clarification: Depending on jurisdiction, advanced practice clinicians and other authorized professionals may sign, when permitted by law and policy.
Legal And Ethical Considerations
State laws govern who can sign and how DNR orders must be documented. Key considerations include:
- Consistency with the patient’s expressed wishes or surrogate decisions
- Clear communication to all members of the care team about the DNR status
- Protecting patient autonomy while ensuring appropriate medical care
- Proper revocation processes if the patient changes their mind or if medical circumstances evolve
Hospitals and many care facilities maintain policy frameworks to reduce confusion, including standardized forms, electronic medical record flags, and staff training on honoring DNR directives in emergencies.
Revisions, Revocations, And Transfers Of Care
A DNR order can be amended or revoked at any time by the patient, or by a legally authorized surrogate, provided the patient has decision-making capacity or the surrogate acts within the scope of their authority. If a patient transfers between care settings, the receiving facility should verify the DNR status and ensure continuity of care. For patients with fluctuating capacity, repeat confirmations and discussions are often advisable, especially when prognosis shifts or new treatments become feasible.
Practical Steps For Clinicians And Families
To ensure a DNR decision is well-founded and respected, consider the following steps:
- Initiate a clear discussion about goals of care early in the illness trajectory or upon admission
- Document the patient’s preferences in plain language and in the chart with explicit CPR instructions
- Ensure the DNR order is easily identifiable by all care teams across settings
- Provide written copies to the patient and surrogate, and discuss revocation and renewal timelines
- Review regularly, especially after major changes in health status or treatment options
In practice, a well-documented DNR aligns clinical actions with the patient’s values, reduces unwanted interventions, and supports compassionate care during emergencies.