The primary goal of a DNR order is to respect the patient's wishes regarding life-saving measures. This decision is often made by patients with terminal illnesses, severe chronic conditions, or those who do not wish to have their life prolonged by aggressive medical interventions.

A DNR order is legally binding and must be respected by healthcare providers. It is based on the principles of patient autonomy and informed consent. Patients have the right to make decisions about their own healthcare, including the refusal of certain treatments.

Deciding on a DNR order can be emotionally challenging. It is important for patients and their families to have open, honest conversations about the patient's values, prognosis, and preferences for end-of-life care.

Some patients may opt for a "DNI" (Do Not Intubate) order, which allows for CPR but not intubation (insertion of a breathing tube). Others might specify other preferences for the extent and type of medical interventions they are willing to undergo.

The DNR order to be recommended by THREE doctors. ONE is the attending physician as a consultant and the other TWO doctors not less than specialists. The three physicians must be well informed about the patient's condition in order to make a decision on the DNR status of the patient, and they should all sign the medical record of the patient. The recommendation should include:

• A brief description of the patient's medical condition, supporting the terminal nature of the life-threatening disease.
• Reference to any medical consultations supporting the decision of DNR.
• Refer to the discussions concerning the prognosis or the decision of DNR with the patient, his/her family significant other or guardian.

When appropriate or necessary, the attending consultant will personally (or designate one of the other TWO physicians signing the DNR order) discuss the DNR decision with the patient and/or an adult next of kin (or surrogate decision― maker) to inform about the decision. The appropriateness (or otherwise) of this Communication is the decision of the attending consultant who knows the patient′ and the family may be in a better position to predict the patient′ s response to such discussion.

All DNR orders for a patient must be documented and signed by the attending consultant and two other specialist physicians (a total of three) on the patient′ s medical record with the DNR order form. The order may be initially given by telephone to his/her designee if the consultant not avail able at the hospital, in accordance with the existing telephone order procedure for general clinical orders, but such orders must be signed by the consultant within 24 hours.

• Clear Documentation: Ensure the DNR order is clearly documented in the patient's medical record and that all members of the healthcare team are aware of it
• Family Communication: Maintain open lines of communication with the patient’s family and loved ones. Ensure they understand the DNR order and what it entails
• Regular Review: Periodically review the DNR order with the patient (if capable) and their family to confirm it still reflects the patient’s wishes

• Comfort Measures: Focus on providing comfort care, including pain management, emotional support, and alleviation of distressing symptoms. This is often referred to as palliative care.
• Holistic Approach: Address physical, emotional, social, and spiritual needs of the patient.
• Avoid Unwanted Interventions: Ensure that no resuscitative efforts (CPR, defibrillation, intubation) are performed if the patient’s heart stops or they stop breathing.

• Interdisciplinary Team: Engage a multidisciplinary team including doctors, nurses, social workers, and chaplains to provide comprehensive care.
• Handoff Communication: During transitions of care (e.g., shift changes, transfers between units), ensure that the DNR status is clearly communicated to all relevant staff.

• Respect Autonomy: Always respect the patient’s autonomy and their right to make decisions about their own care.
• Legal Compliance: Ensure that the DNR order complies with state and local laws and institutional policies.
• Advance Directives: Encourage the patient to have other advance directives in place, such as a living will or healthcare proxy, to guide care in various situations.

• Educate Family and Caregivers: Provide education to the family and caregivers about what a DNR order means and what to expect.
• Emotional Support: Offer counseling services or support groups to help the patient and family cope with emotional and psychological stress.

• Clear Action Plan: Have a clear plan in place for how to manage a situation where the patient’s condition deteriorates. This includes knowing who to call, what interventions are allowed, and how to provide comfort care.
• Immediate Response: In the event of a crisis (e.g., respiratory distress, severe pain), provide immediate symptomatic relief without initiating resuscitative efforts.

• Reflective Practice: Regularly reflect on the care provided to ensure that it aligns with the patient’s wishes and high standards of ethical practice.
• Continuous Improvement: Use feedback from patients, families, and the healthcare team to continuously improve the management of DNR patients.

Comfort Care: Patients often request measures to ensure comfort, including pain management, anxiety reduction, and relief from other distressing symptoms.

Non-Invasive Treatments: Requests may include non-invasive treatments like oxygen therapy, medications for symptom control, and hydration.

Palliative Care: Many DNR patients ask for comprehensive palliative care to improve quality of life through holistic support addressing physical, emotional, and spiritual needs.

Hospice Care: If the patient is in the final stages of a terminal illness, they may request hospice care, which focuses on comfort rather than curative treatments.

• Refusal of Certain Interventions: Specific requests to refuse certain medical interventions, such as intubation, mechanical ventilation, or feeding tubes, in alignment with the DNR order.
• Allowing Natural Death: Ensuring that the patient’s natural death is allowed without attempts to restart the heart or breathing, consistent with the DNR order.

• Counseling Services: Access to counseling services for the patient and their family to help cope with the emotional aspects of end-of-life decisions.
• Spiritual Care: Requests for visits from chaplains or spiritual advisors to provide comfort and support according to the patient’s beliefs and values.

• Interdisciplinary Care Team: Involvement of an interdisciplinary care team, including doctors, nurses, social workers, and other healthcare professionals, to provide coordinated and comprehensive care.
• Home Care Services: Arrangements for home care services if the patient prefers to stay at home rather than in a hospital or hospice setting.