Living Wills and DNR Orders – Just the Beginning of the Conversation

A physician friend who knows I speak about the importance of Living Wills and Advance Directives shared the column of Dr. Nathan Laufer in the June issue of Maricopa County Medical Society’s ROUND-UP magazine (go to www.mcmsonline.comfor the electronic version). Dr. Laufer shares several poignant stories about patients who  requested “no code” orders without understanding that they were therefore refusing simple procedures that would allow them to leave the hospital more quickly, or not permitting hospital staff to place them on mechanical life support during surgery.  In Dr. Laufer’s experience, many patients who are given a checklist upon their admission to the hospital do not understand the implications of the “no code” or “Do Not Resuscitate” boxes, and admissions staff do not provide adequate explanations, or may not even be asked to do so.

The practice of requiring patients to state their preferences on DNR orders, or to complete Living Wills, dates back to the Patient Self-Determination Act of 1991, which requires healthcare  facilities to discuss advance directives with incoming patients.  Estate planning attorneys, and then state legislatures, followed with Living Wills that allow individuals to state their preferences regarding care – and the withholding of care – in more general circumstances. (See  for a Living Will form that meets the requirements of Arizona law.)  Still, more than two-thirds of all Americans, including almost half of us who are over the age of 65, have not completed Advance Directives.  Dr. Laufer points out that, even when those directives are in place, it is hard to tell whether the information is available to the care providers in a manner that could affect their treatment decisions. 

I often point out that the best thing about completing advance directives are the family discussions they generate.  Many parents are surprised to learn that the child to whom they would like to give their Medical Power of Attorney has a completely different view about end-of-life care than they do.  In the best of these situations, the parent’s request that their child take on this role inspires an important conversation about values and the way our perspective on death changes as we age.  The legal document does not necessarily provide the answers, but it does  provide the starting point for family members to ask the right questions of each other.

Dr. Laufer points out that the Living Will and DNR Order should serve the same purpose between physician and patient.  He encourages doctors to ask their patients whether they understand the implications of the boxes they have checked and what they might want to have done in specific situations.  Laws, mandatory procedures and statutory language can only go so far, and none of them can take the place of honest discussion between patients and their doctors and family members.

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