Life, Death, and DNR: An ICU Nurse’s Insight on Compassionate Care
- Jenna Congdon
- 3 days ago
- 9 min read
Bonnie, age 92*: She’s a mother, grandmother, and great-grandmother. Bonnie has a long list of chronic medical problems, but is doing fine at the moment. She lives at home independently, and enjoys gardening and visiting friends from her church.
Carlos, age 37: He’s a father to four young children. He used to work in construction, until he developed a severe lung disease three years ago. He’s been in and out of the hospital a lot, and his condition has been steadily declining.
Linda, age 51: Devoted life partner and friend to many, Linda used to love biking through her community. Two weeks ago, she had a stroke, and she’s been on a ventilator in the ICU since then. Her course has been difficult, with a lot of complications. She’s not expected to recover normal brain function, and she’s unable to move one side of her body.
What do these three people have in common? First and foremost: they’re all loved by supportive families and friends. But medically speaking, where their cases overlap comes down to a simple bracelet on their wrists: they each have a DNR order.
To many, choosing a Do Not Resuscitate (DNR) order for yourself or a loved one means giving up. Families believe their loved one will no longer be cared for, that healthcare staff will treat them differently, or that their medical conditions are untreatable. This myth leads to painful misunderstandings at a time already rife with emotion. In reality, choosing a DNR order often represents a kinder, more compassionate form of care.
What “DNR” Really Means
As an ICU nurse, I see families struggle to grasp what “DNR” really means.
The answer is straightforward: DNR simply means we will not perform CPR if your heart stops.
Cardiopulmonary resuscitation, or CPR, is done as a last-ditch measure for someone who does not have a heart beat, or whose heart rhythm is not compatible with life. It involves giving chest compressions by pressing firmly and rhythmically on the chest bone, and giving breaths to the patient using a mask or machine. Electric shocks may be given to reset the heart’s rhythm. In the hospital, we give medications that can help restore a stable heartbeat or maintain an appropriate blood pressure.
CPR isn’t pretty; it’s aggressive. It looks nothing like on TV. To give effective chest compressions, you have to push hard. The chest needs to dip more than two inches to effectively pump the heart. This takes so much strength that CPR rescuers are taught to switch places every two minutes so they don’t tire.
Ribs break and lungs get bruised. If you’re in the ICU, we quickly place tubes in every hole: mouth, nose, veins, sometimes even into the shin bone. The room is often hushed, with just one person giving orders to the background tune of bones crunching and body fluids being suctioned away.
I paint this unglamorous picture not to frighten, but to inform. Families in crisis often ask medical workers to “do everything” without understanding what that means. Healthcare personnel sometimes struggle to make the actualities of CPR clear in a way that’s both honest and gentle. We quickly ask “if your heart stops, do you want us to try to save you?”. Of course you say yes. Who wouldn’t?
The Aftermath
CPR survival rates are low: just 10% of people who receive CPR outside the hospital will make it through. (1) If you receive CPR in the hospital, that number rises to 21%. But survival alone isn’t the whole picture: many patients never get back to their usual selves after the mental and physical trauma of a CPR rescue. Brain injury after cardiopulmonary arrest is common, with many patients experiencing neurological deficits. (2) This happens more commonly in patients who are older or have a pre-existing serious illness.
Quality of life post-resuscitation is often poor. While some patients do go on to live a full and healthy life, for many, their suffering is prolonged. Roughly 20% of patients experienced poor neurological outcomes that impacted their daily lives.
That said, any chance is better than none. We perform CPR to give patients the best possibility of surviving a cardiac arrest. The message is clear: this is a lifesaving measure, and that comes with a steep cost to the patient’s comfort, dignity, and peace. The media does injustice by portraying it as a guaranteed, mess-free miracle.
How CPR Became the Standard
CPR has its drawbacks, but the procedure certainly does save lives. Forms of mouth-to-mouth ventilation and chest compressions have been done since the 1700s. Not long after, physicians discovered that electric shocks could revive a stopped heart. (3)
Modern science is continuously refining the process. Lay people are taught to call for help, check for a pulse, and start chest compressions at a set rate and depth. They may use an AED, which is a machine that can check if the patient’s condition warrants an electric shock, and administer it if needed.
Medical professionals are trained to insert a tube into the patient’s throat to assist breathing. They give electric shocks and specific medications at set intervals, based on the patient’s heart rhythm.
Unless you specify that you would like to have a DNR order placed in your chart, hospital staff will begin CPR if your heart stops. If you collapse in public, passerby and Emergency Medical Services will do the same. CPR has become the default.
Why is this? Our culture is taught to assume that saving a life at all costs is of utmost importance, without stopping to think of the potential harm done. It’s become not only the medical standard, but a legal expectation. If a healthcare provider does not do CPR and no DNR order is present, they would likely face legal charges.
For the general public, jumping into action is appropriate: the victim didn't have a chance to make their wishes known ahead of time. In the hospital, we often do have the time to have this discussion before the patient's condition deteriorates. The problem is, this opportunity is often missed before it's too late.
The onus falls on the patient and their family to decide if it’s the right choice for their situation. Medical professionals are taught to ask what the patient wants, but rarely have the time or training to explain the full gravitas of the decision.
Myths and Misunderstandings
Most families hesitate when it comes to changing a loved one’s code status. They worry that adding a DNR order to their family member’s chart is abandonment, as if that person will suddenly stop receiving medical care. To some, DNR sounds like a death sentence, like they’ve given up hope for recovery.
This could not be further from the truth. A DNR order is simply a request to forego CPR in the event of a cardiopulmonary arrest. As a nurse, my care of your loved one doesn’t change. They’re still treated for their medical conditions. They get pain medication, antibiotics, therapy, or anything else their case requires. I’m still by their side, giving them the same amount of attentive care that I give each of my patients.
The key is to understand what CPR would or wouldn’t do for your loved one. For patients who have a serious medical condition, like Carlos, are older, like Bonnie, or aren’t expected to have a good quality of life in the future, like Linda, CPR can cause more harm than help.
This is not to say that these people should give up hope, or that they are no longer worthy of medical care. Carlos was ready to fight hard for recovery. He wrote a love letter to each of his children, but stashed them away. “I wrote them just in case”, he told me, “but for now, I know there's more treatment for me”. He chose to make himself a DNR because he understood that if his heart stopped, his chances of survival and a meaningful recovery that would allow him to take part in his children’s lives was frighteningly slim. He knew that his last days would likely be spent on a ventilator, unconscious and unable to say goodbye. He chose the possibility of a dignified death, one that wouldn’t leave the trauma of a code blue imprinted in his family’s memory.
End of Life Care is a Spectrum
It’s important to understand that serious medical care is not an all-or-nothing approach. A patient can choose a DNR order, but still pursue full treatment for their condition. Or, they may decline certain interventions that cause pain or discomfort. This is commonly referred to as “comfort care”. The focus shifts from treating and correcting illness to soothing symptoms and making the patient as comfortable as possible. This is done when it’s understood that the patient may not have much longer to live, and they simply want to enjoy the time they have left.
Each case is different, medically and personally. Relationships, personal opinions, and religious beliefs all play a role in making these decisions. Some families may refuse aggressive care early on, and emphasize the importance of good quality of life. In other situations, the patient may express that they want to live as long as possible, even if it means painful or invasive treatments. It’s crucial to talk with your loved ones about what’s most important to you.
Planning Ahead Saves Heartache
Not everyone has a long lead-up to critical illness, like Carlos. Some, like Linda, have a sudden medical event that no one could have seen coming. Planning ahead and discussing with loved ones what you would want in the event of a medical emergency saves tremendous heartache. At a time when their world has turned upside down, you can save your loved ones the burden of that decision, simply by making your wishes known.
Ask yourself: what does an acceptable quality of life mean to you? I work with one doctor who explains it this way: if he can be put in a wheelchair, pushed to the water’s edge, and handed a fishing rod, he’d be happy to be alive. If he were so debilitated that he could not participate in this simple activity, he would want his family to think twice before pursuing aggressive care. Figure out what your own limits are, and tell those closest to you in clear, decisive terms.
Even if you’re healthy, view this planning head as insurance. You don’t get into your car every morning expecting to crash, and yet you insure your vehicle. You don’t assume your home will flood or burn down, but you insure that, too. It’s not morbid to discuss death; it’s a responsibility we all have.
You can take it a step further and create a Power of Attorney for healthcare. This is a simple document that states your medical wishes and who you would like to make healthcare decisions on your behalf if you were too sick to speak for yourself. Each state has different laws, but the forms are generally easy to fill out. Complete it, sign it, and tell your family where you put the copies.
Dignity & Hope: Why DNR Can Be a Compassionate Choice
So often, CPR is painted as a fail-proof measure that brings everyone back every time, when in fact, it sometimes breaks the medical provider’s goal to “do no harm”.
Choosing a DNR order is not giving up hope; it’s changing what hope looks like. Forgoing CPR allows death to be more comfortable, more compassionate, and more dignified. It gives families the chance to say goodbye in a calm, peaceful environment. The choice does not mean stopping treatment, or that your loved one will receive less care or attention from medical providers.
Opting for a DNR order when a loved one is facing severe illness is a compassionate choice, and a way to demonstrate your love for them. It’s a way to show that you care for their comfort, respect their wishes, and want their time here to be the best it can be.
On the flip side, your loved one may have shared that they do want CPR if their heart stops, even knowing the potentially negative outcomes. This, too, is an informed choice, and one that deserves to be respected and upheld.
The key is to just ask. Have the hard conversation, and get clear on what the people you care about would want in the event of a medical emergency.
This topic is heavy, and no one wants to find themselves facing such a choice. Information is our best tool: be sure you understand the strengths and limitations of CPR. Have a frank discussion with your medical team, decide what’s most important to you, and get that in writing. Then, celebrate! By planning ahead, you’ve taken control of your future and set your loved ones up for success.
Remember, CPR does save lives, but it can also be problematic. End of life care isn’t one-size-fits-all. Being informed and making choices ahead of time that fit your beliefs and goals gives you and your family the gift of peace of mind.
Resources
https://www.resuscitationjournal.com/article/S0300-9572(24)00178-3/fulltext
https://cpr.heart.org/en/resources/history-of-cpr
*Patient identifiers changed to protect privacy.
Assessed and Endorsed by the MedReport Medical Review Board
