Did an ED patient present with a “Do Not Resuscitate” (DNR) order?

“This important question helps guide healthcare providers to provide care that the patients want,” says Catherine A. Marco, MD, FACEP, a professor in the division of emergency medicine at The University of Toledo (OH).

Patients or families potentially could sue EPs either for unwanted interventions or for withholding resuscitative efforts.

“Most important is whether the EP acted in good faith based on information available regarding the patient’s wishes,” Marco stresses.

It’s important to document the patient’s or family’s decisions regarding end-of-life care in the medical record, which may include a DNR order.

“Otherwise, when the patient has a heart attack, and the nurse does not call a code, and the patient dies, the plaintiff could argue that this was neglect,” explains Dean Sittig, PhD, professor in the School of Biomedical Informatics at the University of Texas Health Sciences Center at Houston.

State Laws Vary

State laws vary significantly regarding DNR orders. Some specifically confer legal protection to providers who follow state-approved advance directives.

“Many states confer immunity to providers who in good faith follow Physicians Orders for Life Sustaining Treatment [POLST] orders,” Marco adds. States vary in the specific implementation of POLST; some have enacted statutory legislation, while others have authorized their use through regulations. Still others have developed consensus guidelines without specific legislative or administrative authorization. “Best practices should include reviewing documentation of the patient’s wishes, including any advance directive or POLST,” Marco says.

If the patient can communicate, the patient’s wishes should be clarified. With the patient’s permission, families should be involved in such discussions. “In some circumstances, this may take significant time,” Marco notes.

EPs may need to obtain documents, and possibly involve an institutional ethics committee or obtain a legal opinion. “If patient wishes are uncertain, resuscitative efforts may be appropriate while attempting to clarify patients’ wishes,” Marco adds.


  • Catherine A. Marco, MD, FACEP, Professor, Division of Emergency Medicine, The University of Toledo (OH). Phone: (419) 383-6343. Email: catherine.marco@utoledo.edu.
  • Dean Sittig, PhD, Professor, School of Biomedical Informatics, The University of Texas Health Sciences Center, Houston. Phone: (713) 299-2692. Email: Dean.F.Sittig@uth.tmc.edu.