Does Singapore have Do-Not-Resuscitate (DNR) Order? If yes, where can I register for one?

[SBFNews]

What Is a Do-Not-Resuscitate (DNR) Order? Why Is It Used?
www.goodrx.com
Key takeaways:

• A do-not-resuscitate order is a legal order signed by a physician that specifies you do not want to be resuscitated in an emergency.
• DNR orders are more common among people whose chance of surviving resuscitation is very low.
• DNR orders fall under the umbrella of advance care planning, which provides details about the medical care you want to receive when you cannot make decisions for yourself.

Martin Barraud/OJO Images via Getty Images

A do-not-resuscitate (DNR) order is a legal document signed by you and your provider. It tells emergency responders and other healthcare providers to not perform cardiopulmonary resuscitation (CPR) if your heart stops (called cardiac arrest) or you stop breathing.
In a DNR order, CPR refers to:

• Pressing on the chest or using electricity or medications to restart the heart
• Mouth-to-mouth breathing (if outside of a hospital)
• Placing a breathing tube down your throat and connecting you to a machine called a ventilator

We’ll discuss details about DNR orders and explain some similarities and differences between it and other advance care planning documents.

Does every U.S. state allow DNR orders?​

Every state allows DNR orders, but there are differences in state laws. For example:

• Some states use different terms, such as a do not attempt resuscitation (DNAR) order; a no code order; or an allow natural death (AND) order.
• In some states, only a physician can sign the order, while in others, a nurse practitioner (NP) or physician associate (PA) can sign it.
• Some states require a notary signature or two witnesses to be present at signing.

Unfortunately, most DNR orders are not honored from one state to another state. So if you move from California to Texas, for example, a new DNR order would need to be signed.

Why are DNR orders used?​

DNR orders are used when there is a lower chance of survival with CPR if a person’s heart stops beating.

We often see people survive after CPR on television and in movies. However, we tend to overestimate the success of CPR. It can double or triple the chance of survival, but only 10% to 20% of people actually survive after cardiac arrest outside the hospital. This number is even lower in people with several chronic health conditions and terminal illnesses, like advanced cancer.

Even if a person is brought back to life after CPR, they are not likely to return back to their normal state of health. The following are common afterwards:

• Brain damage
• Heart damage
• Lung injury
• Internal bleeding
• Broken ribs

So, in many cases, the risk of pain and harm from CPR is much higher than the benefits. Some people simply don’t want to be on life support at the end of their days, so they choose a DNR order to prevent that.

You can cancel a DNR order at any time.

What rights does a DNR order provide?​

A DNR order allows you to choose whether or not you want CPR in an emergency. It does not give instructions for other treatments, such as artificial nutrition, intravenous (IV) fluids, or antibiotics.
Many states have adopted another set of orders called the Physician Orders for Life Sustaining Medical Treatment (POLST). The POLST is more detailed than a DNR order. It includes different options for CPR and details on what kind of treatments you want as part of your medical care. (More on this below). The POLST can have different names depending on where you live.

When might someone consider a DNR order?​

Any adult can request a DNR order. The order is commonly considered if a person would likely not benefit from CPR.
Some instances where a person would consider a DNR order include:

• A short time left to live because of a terminal illness
• Serious chronic illnesses, such as congestive heart failure or COPD
• Decreasing quality of life or increasing dependence on others for basic daily needs

Are DNR orders allowed only for people with certain health conditions?​

A DNR order is allowed for any reason. Any adult can request a DNR, including healthy adults. People most likely to use them are those who know in advance that their chance of surviving CPR is very low and/or they don’t want to spend their last days on life support.

Are there circumstances where medical personnel will resuscitate a person even with a DNR order?​

Depending on state laws, medical personnel may resuscitate a person with a DNR order if:

• There is no written documentation of the DNR order.
• They cannot find or confirm the DNR order.
• There is a question whether the DNR is valid.
• The cause of the heart or breathing stopping is from something unnatural, like trauma or a sudden blockage in the airway.

Most states have options for people to wear jewelry that indicates that there is a DNR order. But it is important to check with your state laws to know what type of identification is valid. It is also important to know if the jewelry can work in place of a physical DNR order and which jewelry makers are approved by your state.

If there is any doubt, medical professionals will err on the side of resuscitation. So, if you sign a DNR order, be sure your family knows your wishes and where to find the forms.

Can a family refuse a DNR order?​

If a person has already completed a DNR order, their family cannot refuse the order. If you have a DNR order and your family members disagree, medical personnel will still honor your wishes. But the medical staff will communicate with your family to try to get everyone on the same page with your decision.

What is an advance healthcare directive?​

An advance healthcare directive, or advance directive, is another legal document that details a person’s wishes about their medical decisions ahead of time. It specifically refers to a combination of two main documents: a living will and a durable power of attorney for healthcare (or medical power of attorney).

Even if you don’t have medical issues now, an advanced medical directive can help you when you get very sick or have a medical emergency and can no longer make decisions for yourself.

A living will​

A living will describes the type of treatment a person would want if they are terminally ill or are no longer conscious and cannot make decisions about their care. It is not the same as a last will, which describes who will inherit your property and assets after you die.
A living will give more detailed information about medical care such as:

• A DNR request
• Comfort care measures (such as administering pain medication)
• Artificial breathing
• Artificial nutrition
• Dialysis
• Organ and tissue donation

Note that a DNR request in your living will is not the same as a DNR order. You must communicate your DNR request to your provider. They will then enter a DNR order in your medical record.

Before a living will can be used to guide your healthcare, two physicians have to confirm that you are no longer able to make decisions. It is also required that your medical condition cannot be cured or you are permanently unconscious.

Durable power of attorney for healthcare​

A durable power of attorney (DPOA) is a person you choose to make medical decisions for you if you cannot communicate your wishes. Your medical team will use your living will to guide your medical care, but your DPOA will make decisions about anything not covered in your living will. Note that a DPOA has many other names, including healthcare proxy, healthcare power of attorney, or surrogate.

How is an advance healthcare directive different from a DNR or POLST order?​

All three advance care planning documents guide some aspect of your medical care. The chart below highlights some differences between them.

Differences in advance care planning documents

	Advance healthcare directive	POLST	DNR order
Is it a legal document?	Yes	Yes	Yes
Who typically fills one out?	Any adult	Terminally ill persons, older adults, those with advanced chronic disease	Terminally ill persons, older adults, those with advanced chronic disease
Who is it completed and signed by?	An attorney	A physician	A physician
How long is the document?	Several pages	Usually one to two pages	Usually one to two pages
Can you name a healthcare POA?	Yes	No	No
Is it used by first responders (i.e., paramedics)?	No	Yes	Yes
Is it in your medical record?	No	Yes	Yes

Do you need an advance healthcare directive for a DNR order?​

You do not need an advance healthcare directive for a DNR order. An advance healthcare directive can include a DNR request, but a DNR order itself is a separate medical order from a physician. The DNR order written by your provider is included in your medical record.

The bottom line​

A DNR order specifies when someone doesn’t want CPR in an emergency. Other advance care planning documents offer more detail about medical treatments if you are very sick and can’t communicate your wishes. Rules for DNR orders and other advance care planning documents vary by state, so it is important to check your local laws. Be sure to let your family know your decisions and the location of your documents so your wishes are understood and honored.

References​

American Academy of Family Physicians. (2021). Advance directives and do not resuscitate orders. Familydoctor.org.
American Cancer Society. (2019). What is an advance directive?
American Heart Association. (2021). CPR facts & stats: How CPR is changing (and saving) lives.
American Heart Association. (2021). What is CPR?
Bandolin N., et al. (2020). Perspectives of emergency department attendees on outcomes of resuscitation efforts: Origins and impact on cardiopulmonary resuscitation preference. Emergency Medicine Journal.
Breault, J. (2011). DNR, DNAR, or AND? Is language important? The Ochsner Journal.
California Medical Association (Accessed 2021). Emergency medical services prehospital do not resuscitate form.
Freewill. (2021). Last will vs. living will: What’s the difference?
Institute for Healthcare Improvement (2020). Who will speak for you? How to choose and be a health care proxy.
Luth, E., et al. (2021). Dementia and early do-not-resuscitate orders associated with less intensive of end-of-life care: A retrospective cohort study. American Journal of Hospice and Palliative Medicine.
Marie Curie. (2019). What does terminal illness mean?
National POLST. (2019). National POLST form.
National POLST. (Accessed 2021). POLST: Portable medical orders for seriously ill or frail.
National POLST.. (Accessed 2021). POLST program names.
National POLST. (Updated 2021). Signature requirements for a valid POLST form by state.
Portanova, J., et al. (2015). It isn’t like this on TV: Revisiting CPR survival rates depicted on popular TV shows. Resuscitation.
Sabatino, C. (2021). Do-not-resuscitate orders. Merck Manual Consumer Version.
Sehatzadeh, S. (2014). Cardiopulmonary resuscitation in patients with terminal illness: An evidence based analysis. Ontario Health Technology Assessment Series.
Texas Department of State Health Services (Revised 2009). Out of hospital do-not-resuscitate (OOH-DNR) order.
Texas Department of State Health Services (Amended 2010). Texas administrative code- out-of-hospital do not resuscitate (OOH-DNR) order.
Walter, K. (2021). Durable power of attorney for health care.

 

[NanoRay]

What Is a Do-Not-Resuscitate (DNR) Order? Why Is It Used?
www.goodrx.com
Key takeaways:

• A do-not-resuscitate order is a legal order signed by a physician that specifies you do not want to be resuscitated in an emergency.
• DNR orders are more common among people whose chance of surviving resuscitation is very low.
• DNR orders fall under the umbrella of advance care planning, which provides details about the medical care you want to receive when you cannot make decisions for yourself.

Martin Barraud/OJO Images via Getty Images

A do-not-resuscitate (DNR) order is a legal document signed by you and your provider. It tells emergency responders and other healthcare providers to not perform cardiopulmonary resuscitation (CPR) if your heart stops (called cardiac arrest) or you stop breathing.
In a DNR order, CPR refers to:

• Pressing on the chest or using electricity or medications to restart the heart
• Mouth-to-mouth breathing (if outside of a hospital)
• Placing a breathing tube down your throat and connecting you to a machine called a ventilator

We’ll discuss details about DNR orders and explain some similarities and differences between it and other advance care planning documents.

Does every U.S. state allow DNR orders?​

Every state allows DNR orders, but there are differences in state laws. For example:

• Some states use different terms, such as a do not attempt resuscitation (DNAR) order; a no code order; or an allow natural death (AND) order.
• In some states, only a physician can sign the order, while in others, a nurse practitioner (NP) or physician associate (PA) can sign it.
• Some states require a notary signature or two witnesses to be present at signing.

Unfortunately, most DNR orders are not honored from one state to another state. So if you move from California to Texas, for example, a new DNR order would need to be signed.

Why are DNR orders used?​

DNR orders are used when there is a lower chance of survival with CPR if a person’s heart stops beating.

We often see people survive after CPR on television and in movies. However, we tend to overestimate the success of CPR. It can double or triple the chance of survival, but only 10% to 20% of people actually survive after cardiac arrest outside the hospital. This number is even lower in people with several chronic health conditions and terminal illnesses, like advanced cancer.

Even if a person is brought back to life after CPR, they are not likely to return back to their normal state of health. The following are common afterwards:

• Brain damage
• Heart damage
• Lung injury
• Internal bleeding
• Broken ribs

So, in many cases, the risk of pain and harm from CPR is much higher than the benefits. Some people simply don’t want to be on life support at the end of their days, so they choose a DNR order to prevent that.

You can cancel a DNR order at any time.

What rights does a DNR order provide?​

A DNR order allows you to choose whether or not you want CPR in an emergency. It does not give instructions for other treatments, such as artificial nutrition, intravenous (IV) fluids, or antibiotics.
Many states have adopted another set of orders called the Physician Orders for Life Sustaining Medical Treatment (POLST). The POLST is more detailed than a DNR order. It includes different options for CPR and details on what kind of treatments you want as part of your medical care. (More on this below). The POLST can have different names depending on where you live.

When might someone consider a DNR order?​

Any adult can request a DNR order. The order is commonly considered if a person would likely not benefit from CPR.
Some instances where a person would consider a DNR order include:

• A short time left to live because of a terminal illness
• Serious chronic illnesses, such as congestive heart failure or COPD
• Decreasing quality of life or increasing dependence on others for basic daily needs

Are DNR orders allowed only for people with certain health conditions?​

A DNR order is allowed for any reason. Any adult can request a DNR, including healthy adults. People most likely to use them are those who know in advance that their chance of surviving CPR is very low and/or they don’t want to spend their last days on life support.

Are there circumstances where medical personnel will resuscitate a person even with a DNR order?​

Depending on state laws, medical personnel may resuscitate a person with a DNR order if:

• There is no written documentation of the DNR order.
• They cannot find or confirm the DNR order.
• There is a question whether the DNR is valid.
• The cause of the heart or breathing stopping is from something unnatural, like trauma or a sudden blockage in the airway.

Most states have options for people to wear jewelry that indicates that there is a DNR order. But it is important to check with your state laws to know what type of identification is valid. It is also important to know if the jewelry can work in place of a physical DNR order and which jewelry makers are approved by your state.

If there is any doubt, medical professionals will err on the side of resuscitation. So, if you sign a DNR order, be sure your family knows your wishes and where to find the forms.

Can a family refuse a DNR order?​

If a person has already completed a DNR order, their family cannot refuse the order. If you have a DNR order and your family members disagree, medical personnel will still honor your wishes. But the medical staff will communicate with your family to try to get everyone on the same page with your decision.

What is an advance healthcare directive?​

An advance healthcare directive, or advance directive, is another legal document that details a person’s wishes about their medical decisions ahead of time. It specifically refers to a combination of two main documents: a living will and a durable power of attorney for healthcare (or medical power of attorney).

Even if you don’t have medical issues now, an advanced medical directive can help you when you get very sick or have a medical emergency and can no longer make decisions for yourself.

A living will​

A living will describes the type of treatment a person would want if they are terminally ill or are no longer conscious and cannot make decisions about their care. It is not the same as a last will, which describes who will inherit your property and assets after you die.
A living will give more detailed information about medical care such as:

• A DNR request
• Comfort care measures (such as administering pain medication)
• Artificial breathing
• Artificial nutrition
• Dialysis
• Organ and tissue donation

Note that a DNR request in your living will is not the same as a DNR order. You must communicate your DNR request to your provider. They will then enter a DNR order in your medical record.

Before a living will can be used to guide your healthcare, two physicians have to confirm that you are no longer able to make decisions. It is also required that your medical condition cannot be cured or you are permanently unconscious.

Durable power of attorney for healthcare​

A durable power of attorney (DPOA) is a person you choose to make medical decisions for you if you cannot communicate your wishes. Your medical team will use your living will to guide your medical care, but your DPOA will make decisions about anything not covered in your living will. Note that a DPOA has many other names, including healthcare proxy, healthcare power of attorney, or surrogate.

How is an advance healthcare directive different from a DNR or POLST order?​

All three advance care planning documents guide some aspect of your medical care. The chart below highlights some differences between them.

Differences in advance care planning documents

	Advance healthcare directive	POLST	DNR order
Is it a legal document?	Yes	Yes	Yes
Who typically fills one out?	Any adult	Terminally ill persons, older adults, those with advanced chronic disease	Terminally ill persons, older adults, those with advanced chronic disease
Who is it completed and signed by?	An attorney	A physician	A physician
How long is the document?	Several pages	Usually one to two pages	Usually one to two pages
Can you name a healthcare POA?	Yes	No	No
Is it used by first responders (i.e., paramedics)?	No	Yes	Yes
Is it in your medical record?	No	Yes	Yes

Do you need an advance healthcare directive for a DNR order?​

You do not need an advance healthcare directive for a DNR order. An advance healthcare directive can include a DNR request, but a DNR order itself is a separate medical order from a physician. The DNR order written by your provider is included in your medical record.

The bottom line​

A DNR order specifies when someone doesn’t want CPR in an emergency. Other advance care planning documents offer more detail about medical treatments if you are very sick and can’t communicate your wishes. Rules for DNR orders and other advance care planning documents vary by state, so it is important to check your local laws. Be sure to let your family know your decisions and the location of your documents so your wishes are understood and honored.

References​

American Academy of Family Physicians. (2021). Advance directives and do not resuscitate orders. Familydoctor.org.
American Cancer Society. (2019). What is an advance directive?
American Heart Association. (2021). CPR facts & stats: How CPR is changing (and saving) lives.
American Heart Association. (2021). What is CPR?
Bandolin N., et al. (2020). Perspectives of emergency department attendees on outcomes of resuscitation efforts: Origins and impact on cardiopulmonary resuscitation preference. Emergency Medicine Journal.
Breault, J. (2011). DNR, DNAR, or AND? Is language important? The Ochsner Journal.
California Medical Association (Accessed 2021). Emergency medical services prehospital do not resuscitate form.
Freewill. (2021). Last will vs. living will: What’s the difference?
Institute for Healthcare Improvement (2020). Who will speak for you? How to choose and be a health care proxy.
Luth, E., et al. (2021). Dementia and early do-not-resuscitate orders associated with less intensive of end-of-life care: A retrospective cohort study. American Journal of Hospice and Palliative Medicine.
Marie Curie. (2019). What does terminal illness mean?
National POLST. (2019). National POLST form.
National POLST. (Accessed 2021). POLST: Portable medical orders for seriously ill or frail.
National POLST.. (Accessed 2021). POLST program names.
National POLST. (Updated 2021). Signature requirements for a valid POLST form by state.
Portanova, J., et al. (2015). It isn’t like this on TV: Revisiting CPR survival rates depicted on popular TV shows. Resuscitation.
Sabatino, C. (2021). Do-not-resuscitate orders. Merck Manual Consumer Version.
Sehatzadeh, S. (2014). Cardiopulmonary resuscitation in patients with terminal illness: An evidence based analysis. Ontario Health Technology Assessment Series.
Texas Department of State Health Services (Revised 2009). Out of hospital do-not-resuscitate (OOH-DNR) order.
Texas Department of State Health Services (Amended 2010). Texas administrative code- out-of-hospital do not resuscitate (OOH-DNR) order.
Walter, K. (2021). Durable power of attorney for health care.

Think again. Maybe they have chio Indian nurses to give you mouth to mouth resuscitation.