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In NY State, in the USA, If an otherwise healthy person has a do not resuscitate order and has a heart attack and the ambulance comes, will they just let him die like that? Or is do not resuscitate only applicable to terminally ill people?

  • The answer varies from country to country, and within the US it varies from state to state, so this isn't really answerable. Can you at least narrow it down to a single country? – Carey Gregory Jan 29 '18 at 5:15
  • @CareyGregory done – larry909 Jan 29 '18 at 5:19
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The MOLST (Medical Orders for Life-Sustaining Treatment) form is an update to the non-hospital DNR, which as you saw in a previous answer has very stringent (and frankly unrealistic) requirements.

The MOLST is printed on bright pink paper, and EMS providers are trained to look for it upon entering a house. In addition, patients are able to wear a metal bracelet stating "DNR" if they have a valid MOLST or non-hospital DNR form that states the patient is DNR, and EMS services are trained to treat this bracelet the same as the form itself.

The MOLST does need to be signed by a physician, but any signed MOLST is considered valid unless there is a more recent form or there is other evidence to suggest that the wishes of the patient have changed. This eliminates the 90-day renewal requirement of the non-hospital DNR.

The one limitation I could find is that a MOLST is not valid for psychiatric patients or patients with developmental disabilities.

Many healthy people have DNR forms. In fact, whether or not you want a DNR is a part of an advance directive (here's the form for New York), which every person is encouraged to have, regardless of health status. Here is an interesting essay that provides anecdotal evidence about doctors with no health problems of their own choosing to have a DNR order in place. A doctor is likely to ask you questions about your advance directive in order to make sure that you are not depressed or suicidal (which would invalidate the MOLST), but there are many good reasons for not wanting aggressive care. A good doctor will respect your decisions about the medical care you want to receive.

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    Clearly EMS will honor a valid DNR regardless of the patient's prior medical history, but that still leaves the question of whether a perfectly healthy person could obtain a DNR. Since it requires a physician's signature and I have a hard time seeing any physician signing off on such a DNR, I suspect the answer is no. – Carey Gregory Jan 29 '18 at 18:07
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    Nope, tons of healthy people (including doctors) have DNRs. I've edited my response to reflect that. – Nate Jan 29 '18 at 18:19
  • Interesting. Things have changed in the last 10 years. Go figure. – Carey Gregory Jan 30 '18 at 5:25
  • Is there conditions and levels of DNRs? Like the healthy doctors you mentioned. Does the DNR specify in which case it's applicable? If they were hit by a car and stopped breathing, would they not want to be revived? – larry909 Feb 2 '18 at 12:48
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    The original, more "old school" DNR let you decide yes or no on both "Do Not Resuscitate" and "Do Not Intubate". The newer MOLST forms and other advance directives let you give much more specific information regarding what type of treatment you want, and whether you'd be OK doing it short term or long term. molst-ma.org/sites/molst-ma.org/files/… – Nate Feb 2 '18 at 15:43
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If the person has a valid out of hospital DNR order, then that person should not be resuscitated if they experience a cardio respiratory arrest. In that case the person clearly is not healthy.

The DNR order has to be reviewed every 90 days by the person's doctor. And in the event of an arrest can be overridden by a relative or physician where the person is unable to object.

https://www.health.ny.gov/professionals/ems/policy/99-10.htm

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    So what you're saying is that an otherwise healthy person cannot have a DNR. Yes? It has to be approved by a doctor? – larry909 Jan 29 '18 at 9:10
  • Yes, needs doctor to sign the form to validate it. – Graham Chiu Jan 29 '18 at 9:33
  • Actually I think this information is outdated (published 1999), see my answer below re: the MOLST form (published 2010). – Nate Jan 29 '18 at 13:38
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If an otherwise healthy person has a do not resuscitate order and has a heart attack and the ambulance comes, will they just let him die like that? Or is do not resuscitate only applicable to terminally ill people?

This is a very interesting question. And as a non-American, I am quite shocked by the answer.

To begin with, what you are essentially asking is does an express refusal override implied consent? Morally, yes: the whole point about autonomy is that people have the right to make bad decisions about their life.

The matter is complicated because such a directive has to be explicitly known by the person. So let's simplify things: suppose you have a "Do Not Resuscitate" tattoo on your chest. This is unambiguously stating your express refusal to be resuscitated, like so:

enter image description here

The following case study from Miami, FL was reported in NEJM just a few months ago:

http://www.nejm.org/doi/full/10.1056/NEJMc1713344

An Unconscious Patient with a DNR Tattoo

We present the case of a person whose presumed code-status preference led him to tattoo “Do Not Resuscitate” on his chest. Paramedics brought an unconscious 70-year-old man with a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation to the emergency department, where he was found to have an elevated blood alcohol level. The staff of the medical intensive care unit evaluated him several hours later when hypotension and an anion-gap metabolic acidosis with a pH of 6.81 developed. His anterior chest had a tattoo that read “Do Not Resuscitate,” accompanied by his presumed signature (Figure 1).

A good case how to make your express refusal known, right? Nope, not quite:

We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty. This decision left us conflicted owing to the patient’s extraordinary effort to make his presumed advance directive known; therefore, an ethics consultation was requested.

Regarding your question about New York state, can such a directive still be ignored? Yes, it would seem so. Though granted, there is a recent update to the matter:

Cuomo on Nov. 29 signed the legislation that will add “attending nurse practitioner” to the list of health care providers that patients and families can tap to create various directives related to end-of-life decisions.

https://libn.com/2017/11/30/state-lets-nps-sign-off-on-do-not-resuscitate/

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    In the state I live in, DNR orders outside of a hospital or physician's office have strict rules. An EMT in my state cannot legally honor something like that tattoo. It would be legally meaningless. – Carey Gregory Feb 6 '18 at 20:44

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