SENIOR POWER: DNR and the facts of life

By Helen Rippier Wheeler,
Thursday August 01, 2013 - 05:08:00 PM

This is about DNR, not DNA. DNR stands for Do Not Resuscitate. As in “revive.”

Advance directives and living wills are documents written by individuals, in order to declare their wishes for care, in case they are no longer able to speak for themselves. A DNR differs from an advance directive or living will. A physician or hospital staff member writes a DNR "physician's order," based on wishes previously expressed by the patient in an advance directive or living will. He or she has previously used an advance directive to appoint an agent.

Sounds easy. It isn’t. There are no guarantees, although there are assumptions galore. Not everyone has family or even close friends, who may not be keen on functioning as somebody’s agent. Many physicians resist anything that sounds remotely end-of-life related. You’re likely to see in the waiting room old issues of golf and architectural subscriptions, rather than Compassion & Choices or Ms Magazine or The Journal of Women & Aging… 

In medicine, a "DNR", sometimes called a "No Code", is a legal order written either in the hospital or on a legal form to respect the wishes of a patient not to undergo CPR or advanced cardiac life support (ACLS) if their heart were to stop or they were to stop breathing. A DNR does not affect any treatment other than that which would require intubation, CPR or defibrillation. Patients who are DNR can continue to get chemotherapy, antibiotics, dialysis, or any other appropriate treatments. 

In the United States, an advance directive or living will is not sufficient to ensure a patient is treated under the DNR protocol, even if it is her or his wish, because neither an advance directive nor a living will is a legally binding document. The wishes expressed in an advance directive or living will are not binding. Here are some things you can do to make it more likely that your wishes will be honored: 

Complete the POLST (Physician Orders for Life-Sustaining Treatment) form. It indicates which types of life-sustaining treatment a seriously ill patient wants. POLST helps give patients more control over their end-of-life care, and should complement an advance directive, not take the place of it. POLST has been in use since January 2009. Changes were made to the form based on actual usage from the medical field. (Previously-filled out POLST forms are still valid.) Because the POLST must be signed by your physician, speak to her/him to obtain a copy. POLST forms are printed on pink card stock so they are easily recognizable by emergency medical staff. Unlike traditional physician’s orders, POLST is not bound to a particular site. Rather, the orders contained within a POLST must be honored across care settings and hence may be used by EMTs, physicians, nurses, in the emergency department, hospitals, nursing facilities, etc. 

Post your own DNR notice on your apartment door or within your apartment (not in the refrigerator, as suggested to some tenants), and hope the paramedics heed its meaning. Carry a DNR notice in your wallet or purse. 

Check with your physician that a California Medical Association “Emergency Medical Services Prehospital do not resuscitate (DNR) Form” is in your file. You can find information about this form online. 

Wear a DNR bracelet (or necklace.) While having a bracelet will improve the chances that your wishes will be honored, there are no guarantees as to what will happen in an emergency situation. You can identify companies that sell DNR bracelets via the Internet, e.g. American Medical ID, Colonial Medical Assisted Devices, and Medic Alert. Depending on what state you live in, there are great variations. Some require that only bracelets that have been purchased with a doctor's prescription will be honored, while in others any bracelet will do. 




California Health Advocates has received reports about insurance company agents who are visiting senior apartment complexes, distributing false information, scaring people by telling them that in the autumn they will not be able to see their regular providers unless they sign up with the agent’s company. Agents who are scaring seniors with false information may be doing so deliberately to secure an enrollment commission or may misunderstand a new demonstration called Cal MediConnect, slated to begin no earlier than January 1, 2014 in 8 selected counties including Alameda, San Mateo and Santa Clara. The goal is to integrate Medicare and Medi-Cal benefits for individuals eligible for both programs, commonly called duals or Medi-Medis. Report incidents to Senior Medicare Patrol office at 855-613-7080.  


Representative Darrell Issa (R-CA) is proposing that the U.S Postal Service phase out door-to-door delivery. Service would be shifted curbside [like trash] and to neighborhood cluster boxes [like RFD]. The Postal Service has been moving toward collective deliveries at shopping malls, business parks and new residential developments. Issa's proposal would allow for free hardship exemptions and door-to-door deliveries for “small, unspecified fees.” The National Letter Carriers Union opposes ending six-day and door-to-door deliveries, which it says would hurt jobs and harm the elderly and shut-ins who would have difficulty receiving [and paying for] mail. Issa, the powerful chairman of the House Oversight and Government Reform Committee, has a long history of attacking the postal service, which does not receive federal assistance; it gets revenue from postage sales, delivery services and other products. Now he has taken advantage of a crisis to get his committee to vote twenty-two to seventeen in favor of a “Postal Reform Act of 2013” (H.R. 2748) that American Postal Workers Union president Cliff Guffey warns “will lead to the demise of the Postal Service.”  


“Assisted living” is one of several, often-related terms that senior citizens need to understand. Others are Section 8 subsidized rent, low-income housing, affordable housing, public housing, housing authority. On Tuesday, July 30, 2013 PBS FRONTLINE broadcast the results of an investigation into the operations of Emeritus Senior Living, the largest assisted living company in the U.S., titled “Life and Death in Assisted Living.”  

More and more elderly Americans are electing to spend their later years in assisted living facilities, intended for people who cannot live on their own, but who do not need the standard of 24/7 medical care nursing homes provide. And of course, these particular elderly Americans can afford the cost of assisted living facilities—or they have families who can. 

“…there's really no specific definition of what ‘assisted living’ means, though there's no question this type of care has become a multi-billion-dollar a year business in the U.S. Because there are 50 states, and licensing and regulation of assisted care facilities happen at the state level, oversight and enforcement are inconsistent, often loose. Couple that with a quest for profits and you've got a situation causing nationwide concern as to whether some practices in the industry might be putting senior citizens at risk. 

FRONTLINE and ProPublica discuss the issue of one senior who took a fall at one of Emeritus' facilities and was found face down on the floor. Suffering from dementia, she was taken to the hospital alone because the facility didn't have enough staff to go with her to the hospital and talk to doctors on her behalf. When she returned, she was put in a bed and her condition began to deteriorate, until she developed pressure ulcers and extensive skin damage. She stayed at Emeritus' Emerald Hills facility for weeks, even though the laws of the state prohibit seniors with such serious wounds to remain in assisted living.”  

Emerald Hills is a neighborhood in Redwood City, California.