Understanding CPR and DNR orders

Approved by the Cancer.Net Editorial Board, 11/2012

Key Messages:

  • CPR is used restore a person’s heart rhythm and breathing, but it is rarely successful for someone with incurable cancer.
  • A DNR is a legal order that tells the health care team not to give CPR if a person’s heart and/or breathing stop.
  • Discuss DNR orders and other end-of-life care issues with the patient’s health care team before a crisis occurs.

About CPR

CPR (cardiopulmonary resuscitation) is a combination of chest compressions and rescue breathing given to a person whose heart has stopped beating and who has stopped breathing.  CPR can temporarily help a small amount of blood flow to the heart and brain and attempts to get the heart to beat again.  CPR may include the following:

  • Manual chest compressions (performed using the hands)
  • Defibrillation (a brief electric shock applied to the chest to restore a normal heart rhythm)
  • The use of drugs to stimulate the heart
  • Mouth-to-mouth breathing
  • Bag-valve mask ventilation (the use of a football-size bag, attached to a face mask, that is squeezed by hand to push air into the lungs)
  • Insertion of breathing tube down the throat into the lungs

It is important to know that for patients with cancer, especially those with advanced, terminal, or end-stage cancer, CPR rarely works. Fewer than 5% of people with a serious illness will recover enough to be released from the hospital after CPR.

What CPR does

CPR does not usually restore a person’s regular heart rhythm. If it does, the person will not be able to breathe without assistance and will be placed on a mechanical ventilator, or artificial respirator, which pumps oxygen into the lungs and breathes for the person with cancer. Being placed on a ventilator is sometimes referred to as being "on life support." While on a ventilator, the patient cannot speak or eat, and will have to remain in the intensive care unit on many intravenous medications (meaning the medications are given through a vein). 

For someone with advanced cancer, the heart, lungs, and other organs will begin to fail as death approaches. Even if CPR is effective, the heart or lungs will likely fail again soon. CPR may also be only partially successful, and the person may suffer brain damage (due to a lack of blood flow and oxygen to the brain) or may have to remain on a ventilator and in the intensive care unit indefinitely.

Do not resuscitate (DNR) orders

A DNR order is a type of advance directive, a document that instructs medical personnel that the person with cancer does not wish to receive CPR if his or her heart and/or breathing stops. Advanced directives only take effect when a person is not able to communicate his or her wishes. A person’s doctors and family members can use them to make sure the patient is receiving the desired care. For instance, medical personnel will automatically perform CPR for a patient in the hospital or a nursing home when his or her heart and/or breathing stops, unless there is a DNR order.

Unlike other advance directives that are written and signed by the individual (such as a living will or a durable power of attorney for health care), a DNR order must be completed and signed by the doctor or other health care provider, such as a hospice nurse practitioner. Once completed, the DNR order is added to your medical record.

Health personnel can only follow a DNR order if they know one exists. It is important to notify doctors, nurses, caregivers, and family members that the person with cancer prefers to avoid CPR. In situations where a patient is transferred from one facility to another, or if a new health care team takes over in the same hospital, regulations from the Health Insurance Portability and Accountability Act (HIPAA) require that the patient restate that this issue has been addressed and that he or she has a strong opinion in favor or against the use of CPR. It may be useful, too, to remind your family members, so they know of your wishes and can help advocate for you if you are unable to do so.

Calling 911 and out-of-hospital DNR orders

In some states, DNR orders do not apply to emergency medical services (EMS) personnel who respond to a 911 call; they are only valid in a hospital. EMS personnel will perform CPR on a person in cardiac or respiratory arrest, even if the person has a DNR order. A 911 call requires an immediate response, and EMS personnel do not have the time to verify a DNR order or to identify the person they are treating. Therefore, caregivers and family members caring at home for someone with a DNR order are advised not to call 911 if the person's heart or breathing stops.

Some states have started out-of-hospital DNR programs that allow EMS personnel to honor DNR orders in people's homes. Out-of-hospital DNR orders may include a special DNR form that is posted in the person's home in a readily accessible location (such as on the refrigerator) and/or a special DNR bracelet worn by the individual. Similar to in-hospital DNR orders, the patient's doctor must sign out-of-hospital DNR orders.

In some states, out-of-hospital DNR orders are also called comfort care DNR orders or physician orders for life-sustaining treatment (POLST), as they allow EMS personnel to provide medications to make the person as comfortable as possible and to help relieve the symptoms and side effects that result from the cancer and cancer treatment. Be sure that your family understands your wishes regarding DNR orders.  This will spare them the trauma of having to make difficult and emotional decisions, and will allow you to remain in control of what medical procedures you desire.  Talk with your doctor or nurse, or contact your state's health department, to find out if your state has an out-of-hospital DNR program.

Points to think about when considering a DNR order

Ideally, decisions about end-of-life care should be made early in the care process before there is a need for them. If a crisis occurs, it may be too late to communicate one’s wishes about a DNR order or other advance directives. In addition, starting the dialogue early on often strengthens the relationship with the health care team.

Although discussing death and dying is difficult and sad, people living with advanced cancer are encouraged to revise and review their wishes for end-of-life care with family and health care professionals. A person can revise his or her goals and plans to reflect new events or changing preferences.

As you make your decision, consider the following points:

  • Do you have strong personal, religious, or spiritual views about dying and care at the end of life?
  • Would CPR likely enable you to return to a quality of life and level of activity that would be acceptable to you?
  • If CPR is performed, you will be placed on a ventilator.  If you do not want to be placed on a ventilator, you should consider not allowing CPR to occur.
  • Do you have strong feelings about dying at home versus in a hospital setting? (CPR may increase the likelihood of dying in a hospital setting)
  • Having a DNR order does not stop any other treatments.  You can still receive any treatments appropriate for your condition, including chemotherapy, radiation therapy, antibiotics or other medications.  Your health care team will always continue to provide medications for comfort and will continue to support you. This is called palliative care or supportive care and is an important part of your treatment plan.

Open communication with your loved ones and your health care team will allow them to provide you with care and support while respecting your wishes.  

More Information

Preparation at the End of Life

End-of-Life Care

Additional resources

LIVESTRONG: Planning Your Medical Future

Family Caregiver Alliance: End-of-Life Choices: CPR & DNR

WebMD: Should I Receive CPR and Mechanical Ventilation?