A chart review of cardiac arrest patients revealed some ED patients at North Shore University Hospital in Manhasset, NY, had undergone CPR despite presenting with valid do not resuscitate (DNR) orders.1

Some charts included complaints from family members, stating providers disregarded the patients’ wishes. “In most cases, the EPs resolved those misunderstandings by explaining that, legally, CPR must be administered until a physical copy of the DNR form is presented,” says Ghania Haddad-Essaihi, MD, the study’s lead author and a research assistant at the North Shore University Hospital department of emergency medicine.

Some relatives presented living wills at the time of cardiac arrest, mistakenly thinking it was the same as a DNR order. “Clearly, in our study, patients with living wills were misinformed, as were their relatives, of the living will’s validity as a DNR order,” Haddad-Essaihi observes.

Of 419 cardiac arrest patients, only 15.51% had a DNR order. “This could be explained by the lack of discussions on end-of-life care goals between patients and their physicians,” Haddad-Essaihi suggests.

Of the 65 patients with DNR orders, 38 were resuscitated anyway. Some DNR orders were not documented anywhere in the medical record. ED staff sometimes failed to recognize DNR orders that were documented. Other patients had advance directives, but no valid DNR order.

“The current system is occasionally failing some patients. I believe we have a duty to try to fix it,” says Daniel Mark Rolston, MD, MSHPM, another of the study’s authors and director of the critical care division in the department of emergency medicine at North Shore University Hospital.

It was not only family members who were confused about the differences between living wills and DNR orders. “Many physicians did not understand what constitutes a legal DNR in the prehospital setting,” Rolston reports.

Fourteen patients had a valid DNR, but received CPR specifically because the paperwork was not readily available to EMS. “Clearly, we need a better way to identify DNR patients during this stressful, time-dependent event for families, rather than a form that is likely sitting in a filing cabinet somewhere,” Rolston offers.

For providers, it is important to understand the laws surrounding valid DNR orders in their state, including who can legally rescind them. “As ED physicians, we have an opportunity to initiate goals of care conversations, especially for patients with chronic illnesses who are frequently visiting our EDs, as well as our frail or geriatric patients,” Rolston says.

Many DNR orders do not account for every situation a patient may face, and EPs have little time to interpret the nuances, says Danielle M. Trostorff, Esq., a health law specialist at Degan, Blanchard & Nash in New Orleans. ED patients are not always coherent, and not all have family members who can produce documents. While nursing homes routinely provide DNR orders to EMS personnel, many patients come to EDs from home or elsewhere, without any documentation. Without a valid, documented DNR order, “when an ER physician has to choose between saving a patient or doing nothing, the physician will choose to save the patient and perform CPR,” Trostorff observes.

If CPR is performed against the patient’s wishes, and the family sues for wrongful prolongation of life, there is evidence that can help the defense, including lack of clear information on the patient’s wishes, the time constraints under which the EP was working, the fact hospital protocols were followed, and anything that conflicted with the patient’s DNR status.

“If the patient is having trouble breathing and is asking for help, the ER physician can rely on this as evidence of the patient’s wishes to be resuscitated,” Trostorff says.


  1. Haddad G, Li T, Turrin D, et al. A descriptive analysis of obstacles to fulfilling the end of life care goals among cardiac arrest patients. Resusc Plus 2021;8:100160.