Editing Do not resuscitate (section)

== Usage by country ==
DNR documents are widespread in some countries and unavailable in others. In countries where a DNR is unavailable, the decision to end resuscitation is made solely by physicians.

A 2016 paper reports a survey of small numbers of doctors in numerous countries, asking "how often do you discuss decisions about resuscitation with patients and/or their family?" and "How do you communicate these decisions to other doctors in your institution?"<ref name="gibbs">{{cite journal | vauthors = Gibbs AJ, malyon AC, Fritz ZB | title = Themes and variations: An exploratory international investigation into resuscitation decision-making | journal = Resuscitation | volume = 103 | pages = 75–81 | date = June 2016 | pmid = 26976676 | pmc = 4879149 | doi = 10.1016/j.resuscitation.2016.01.020 }}</ref> Some countries had multiple respondents, who did not always act the same, as shown below. There was also a question "Does national guidance exist for making resuscitation decisions in your country?" but the concept of "guidance" had no consistent definition. For example, in the US, four respondents said yes, and two said no.

{| class="wikitable" style="font-size: 95%; width: auto;"
|+Doctors' approaches to communication about resuscitation<ref name="gibbs"/>
|-
!Country/Location||Discuss with patient or family||Tell other doctors the decision
|-
|Argentina||Most||Written
|-
|Australia||Most, half||Oral+notes+pre-printed,(2) notes
|-
|Austria||Half||Notes
|-
|Barbados||Half||Oral+notes
|-
|Belgium||Half, rarely||Notes+electronic
|-
|Brazil||Most||Oral+notes
|-
|Brunei||Rarely||Oral+notes
|-
|Canada||Always, most||Oral+notes, oral+notes+electronic, notes+pre-printed
|-
|Colombia||Half||Oral
|-
|Cuba||Always||Oral
|-
|Denmark||Most||Electronic
|-
|France||Most||Pre-printed
|-
|Germany||Always||Oral+notes+electronic
|-
|Hong Kong||Always, half||Notes+pre-printed, oral+notes+pre-printed
|-
|Hungary||Rarely||Oral
|-
|Iceland||Rarely||Notes+electronic
|-
|India||Always||Notes, oral, oral+notes
|-
|Ireland||Most, rarely||Notes (2)
|-
|Israel||Most, half||Oral+notes,(2) notes
|-
|Japan||Most, half||Oral, notes
|-
|Lebanon||Most||Oral+notes+electronic
|-
|Malaysia||Rarely||Notes
|-
|Malta||Most||Notes
|-
|New Zealand||Always||Pre-printed
|-
|Netherlands||Half||Electronic (3)
|-
|Norway||Always, rarely||Oral, notes+electronic
|-
|Pakistan||Always||Notes+electronic
|-
|Poland||Always, most||Oral+notes, notes+pre-printed
|-
|Puerto Rico||Always||Pre-printed
|-
|Saudi Arabia||Always, most||Pre-printed, notes+electronic, oral
|-
|Singapore||Always, most, half||Pre-printed (2), oral+notes+pre-printed, oral+notes+electronic, oral+pre-printed
|-
|South Africa||Rarely||Oral+notes
|-
|South Korea||Always||Pre-printed
|-
|Spain||Always, most||Pre-printed, oral+notes+electronic, oral+notes+pre-printed
|-
|Sri Lanka||Most||Notes
|-
|Sweden||Most||Oral+notes+pre-printed+electronic
|-
|Switzerland||Most, half||Oral+notes+pre-printed, oral+notes+other
|-
|Taiwan||Half, rarely||Notes+pre-printed+other, oral
|-
|UAE||Half||Oral+notes
|-
|Uganda||Always||Notes
|-
|USA||Always, most||Notes, electronic, oral+electronic, oral+notes+electronic, oral+notes+pre-printed+electronic
|-
|}

=== Australia ===
In Australia, Do Not Resuscitate orders are covered by legislation on a state-by-state basis.

In Victoria, a Refusal of Medical Treatment certificate is a legal means to refuse medical treatments of current medical conditions. It does not apply to palliative care (reasonable pain relief; food and drink). An Advanced Care Directive legally defines the medical treatments that a person may choose to receive (or not to receive) in various defined circumstances. It can be used to refuse resuscitation, so as to avoid needless suffering.<ref>{{cite web|url=https://www.dwdv.org.au/resources/dwdv-forms|title=Respect for the right to choose - Resources|publisher=Dying with dignity, Victoria|date=2017|access-date=2017-06-14|archive-date=2017-02-18|archive-url=https://web.archive.org/web/20170218080659/https://www.dwdv.org.au/resources/dwdv-forms|url-status=dead}}</ref>

In NSW, a Resuscitation Plan is a medically authorised order to use or withhold resuscitation measures, and which documents other aspects of treatment relevant at end of life. Such plans are only valid for patients of a doctor who is a NSW Health staff member. The plan allows for the refusal of any and all life-sustaining treatments, the advance refusal for a time of future incapacity, and the decision to move to purely palliative care.<ref>{{cite web |url= http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2014_030.pdf |title=Using resuscitation plans in end of life decisions | publisher = Government of New South Wales Health Department |date=2014-09-08 |access-date=2017-06-14}}</ref>

=== Brazil ===
There is no formally recognized protocol for creating and respecting DNR orders in Brazil's healthcare delivery system. The legality of not administering resuscitation procedures for terminally ill patients has not been clearly defined, leading many providers to practice caution around withholding CPR.<ref name="Putzel 596–602">{{Cite journal|last1=Putzel|first1=Elzio Luiz|last2=Hilleshein|first2=Klisman Drescher|last3=Bonamigo|first3=Elcio Luiz|date=December 2016|title=Ordem de não reanimar pacientes em fase terminal sob a perspectiva de médicos|journal=Revista Bioética|volume=24|issue=3|pages=596–602|doi=10.1590/1983-80422016243159|issn=1983-8042|doi-access=free}}</ref>

Although DNR orders have not been institutionalized in Brazil there has been a significant amount of dialogue around the ethical question of whether or not to withhold resuscitation interventions. In the past two decades the Federal Medical Board of Brazil published two resolutions, CFM 1.805/2006 and CFM 1.995/2012, which address therapeutic limitations in terminally ill patients as well as advanced directives. A recent study also showed that in Brazil's healthcare system CPR is being withheld in scenarios of terminal illness or multiple comorbidities at rates similar to those in North America.<ref name="Putzel 596–602"/>

=== Canada ===
Do not resuscitate orders are similar to those used in the United States. In 1995, the [[Canadian Medical Association]], [[Canadian Hospital Association]], [[Canadian Nursing Association]], and [[Catholic Health Association of Canada]] worked with the [[Canadian Bar Association]] to clarify and create a '''Joint Statement on Resuscitative Interventions''' guideline for use to determine when and how DNR orders are assigned.<ref name="caringtotheend.ca">{{cite web |url= http://www.caringtotheend.ca/body.php?id%3D515%26cc%3D1 |title= Do Not Resuscitate Orders | publisher = Princess Margaret Hospital d|access-date=2012-12-05 |url-status=dead |archive-url=https://web.archive.org/web/20140715000749/http://www.caringtotheend.ca/body.php?id=515&cc=1 |archive-date=2014-07-15 }}</ref> DNR orders must be discussed by doctors with the patient or patient agents or patient's significant others. Unilateral DNR by medical professionals can only be used if the patient is in a vegetative state.<ref name="caringtotheend.ca"/>

=== France ===
In 2005, France implemented its "Patients' Rights and End of Life Care" act. This act allows the withholding/withdrawal of life support treatment and as well as the intensified usage of certain medications that can quicken the action of death. This act also specifies the requirements of the act.<ref name="auto">{{Cite journal|last1=Pennec|first1=Sophie|last2=Monnier|first2=Alain|last3=Pontone|first3=Silvia|last4=Aubry|first4=Régis|date=2012-12-03|title=End-of-life medical decisions in France: a death certificate follow-up survey 5 years after the 2005 act of parliament on patients' rights and end of life|journal=BMC Palliative Care|volume=11|pages=25|doi=10.1186/1472-684X-11-25|issn=1472-684X|pmc=3543844|pmid=23206428 |doi-access=free }}</ref>

The "Patients' Rights and End of Life Care" Act includes three main measures. First, it prohibits the continuation of futile medical treatments. Secondly, it empowers the right to palliative care that may also include the intensification of the doses of certain medications that can result in the shortening the patient's life span. Lastly, it strengthens the principle of patient autonomy. If the patient is unable to make a decision, the discussion, thus, goes to a trusted third party.<ref name="auto"/>

=== Hong Kong ===
Starting in 2000, the [[Hong Kong Medical Association |Medical Council of Hong Kong]] has taken the position that advance directives should be recognized. A Law Reform Commission consultation from 2004 to 2006 resulted in a recommendation that legislation be passed in support of advance directives.<ref>{{Cite web |date=16 August 2006 |title=Substitute Decision-making and Advance Directives in Relation to Medical Treatment - Executive Summary |url=https://www.hkreform.gov.hk/en/docs/rdecisions-e.pdf |access-date=4 April 2023 |website=Law Reform Commission of Hong Kong}}</ref> However, as of 2019 no consensus had been reached on legislation.<ref>{{Cite web |title=LCQ15: Advance directives in relation to medical treatment |url=https://www.info.gov.hk/gia/general/201905/22/P2019052200261p.htm |access-date=2023-04-04 |website=www.info.gov.hk}}</ref>

The [[Hospital Authority |Hong Kong Hospital Authority]] has adopted a set of forms which its doctors will recognize if properly completed. However, their recognition at private hospitals is less clear.<ref>{{Cite web |date=2 July 2020 |title=Guidance for HA Clinicians on Advance Directives in Adults |url=https://www.ha.org.hk/haho/ho/psrm/ADguidelineEng1.pdf |website=Hospital Authority of Hong Kong}}</ref><ref>{{Cite web |title=Senior Community Legal Information Centre - Health & care - Advance Directives - What is an "Advance Directive"? |url=https://s100.hk/en/topics/Health-and-care/Advance-directives/What-is-an-Advance-Directive/ |access-date=2023-04-04 |website=Senior CLIC |date=13 May 2022 |language=en}}</ref>

=== Israel ===
In [[Israel]], it is possible to sign a DNR form as long as the patient is at least 17 years of age, dying, and aware of their actions.<ref>{{cite web |title=Advance Medical Directives and Power of Attorney |url=https://www.health.gov.il/English/Services/Citizen_Services/Pages/DyingPatientRequest.aspx |website=State of Israel Ministry of Health |access-date=22 September 2022}}</ref>

=== Italy ===
In [[Italy]] DNR is included in the Italian law no. 219 of December 22, 2017, "Disposizioni Anticipate di Trattamento" or DAT, also called "biotestamento". The law no.219 "Rules on informed consent and advance treatment provisions", reaffirm the freedom of choice of the individual and make concrete the [[right to health]] protection, respecting the dignity of the person and the quality of life. The DAT are the provisions that every person of age and capable of understanding and wanting can express regarding the acceptance or rejection of certain diagnostic tests or therapeutic choices and individual health treatments, in anticipation of a possible future inability to self-determine. To be valid, the DATs must have been drawn up only after the person has acquired adequate medical information on the consequences of the choices he intends to make through the DAT. With the entry into force of law 219/2017, every person of age and capable of understanding and willing can draw up his DAT. Furthermore, the DATs must be drawn up with: public act authenticated private writing simple private deed delivered personally to the registry office of the municipality of residence or to the health structures of the regions that have regulated the DAT Due to particular physical conditions of disability, the DAT can be expressed through video recording or with devices that allow the person with disabilities to communicate. The DATs do not expire. They can be renewed, modified or revoked at any time, with the same forms in which they can be drawn up. With the DAT it is also possible to appoint a trustee, as long as he is of age and capable of understanding and willing, who is called to represent the signatory of the DAT who has become incapable in relations with the doctor and health facilities. With the Decree of 22 March 2018, the Ministry of Health established a national database for the registration of advance treatment provisions. Without the expression of any preference by the patient, Physicians must attempt to resuscitate all patients regardless of familial wishes.<ref>[[:it:law no.219 https://www.gazzettaufficiale.it/eli/id/2018/1/16/18G00006/sg]]</ref>

=== Japan ===
In Japan, DNR orders are known as Do Not Attempt Resuscitation (DNAR). Currently, there are no laws or guidelines in place regarding DNAR orders but they are still routinely used.<ref>{{Cite journal|last1=Nakagawa|first1=Yoshihide|last2=Inokuchi|first2=Sadaki|last3=Kobayashi|first3=Nobuo|last4=Ohkubo|first4=Yoshinobu|date=April 2017|title=Do not attempt resuscitation order in Japan|journal=Acute Medicine & Surgery|volume=4|issue=3|pages=286–292|doi=10.1002/ams2.271|pmc=5674456|pmid=29123876}}</ref> A request to withdraw from life support can be completed by the patient or a surrogate.<ref name="Rubulotta 203–208">{{Cite journal|last1=Rubulotta|first1=F.|last2=Rubulotta|first2=G.|last3=Santonocito|first3=C.|last4=Ferla|first4=L.|last5=Celestre|first5=C.|last6=Occhipinti|first6=G.|last7=Ramsay|first7=G.|date=March 2010|title=End-of-life care is still a challenge for Italy|url=https://www.ncbi.nlm.nih.gov/pubmed/20203548|journal=Minerva Anestesiologica|volume=76|issue=3|pages=203–208|issn=1827-1596|pmid=20203548}}</ref> In addition, it is common for Japanese doctors and nurses to be involved in the decision-making process for the DNAR form.<ref>{{Cite journal|last=Cherniack|first=E P|date=2002-10-01|title=Increasing use of DNR orders in the elderly worldwide: whose choice is it?|url= |journal=Journal of Medical Ethics|volume=28|issue=5|pages=303–307|doi=10.1136/jme.28.5.303|pmc=1733661|pmid=12356958}}</ref>

=== Jordan ===
DNRs are not recognized by [[Jordan]]. Physicians attempt to resuscitate all patients regardless of individual or familial wishes.<ref name="The Globe and Mail">{{cite news |title = Mideast med-school camp: divided by conflict, united by profession |url = https://www.theglobeandmail.com/life/health/mideast-med-school-camp-divided-by-conflict-united-by-profession/article1257723/ |access-date = 2009-08-22 |date = August 2009 |work = The Globe and Mail |quote = In hospitals in Jordan and Palestine, neither families nor social workers are allowed in the operating room to observe resuscitation, says Mohamad Yousef, a sixth-year medical student from Jordan. There are also no DNRs. "If it was within the law, I would always work to save a patient, even if they didn't want me to," he says. |archive-date = 2009-08-21 |archive-url = https://web.archive.org/web/20090821122052/http://www.theglobeandmail.com/life/health/mideast-med-school-camp-divided-by-conflict-united-by-profession/article1257723/ |url-status = dead }}</ref>

=== Nigeria ===
There is no formally accepted protocol for DNRs in Nigeria's healthcare delivery system. Written wills may act as a good guide in many end of life scenarios, but often physicians and/or patients' families will act as the decision makers. As quoted in a 2016 article on Advanced Directives in Nigeria, "everything derives from communal values, the common good, the social goals, traditional practices, cooperative virtues and social relationship. Individuals do not exist in a vacuum but within a web of social and cultural relationships." It is important to note that there are vast cultural differences and perspectives on end of life within Nigeria itself between regions and communities of different ancestry.<ref>{{Cite journal|last1=Jegede|first1=Ayodele Samuel|last2=Adegoke|first2=Olufunke Olufunsho|date=November 2016|title=Advance Directive in End of Life Decision-Making among the Yoruba of South-Western Nigeria|journal=BEOnline |volume=3|issue=4|pages=41–67|doi=10.20541/beonline.2016.0008|issn=2315-6422|pmc=5363404|pmid=28344984}}</ref>

=== Saudi Arabia ===
In [[Saudi Arabia]] patients cannot legally sign a DNR, but a DNR can be accepted by order of the primary physician in case of terminally ill patients.

=== Taiwan ===
In [[Taiwan]], patients sign their own DNR orders, and are required to do so to receive hospice care.<ref>{{cite journal | vauthors = Fan SY, Wang YW, Lin IM | title = Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision | journal = BMC Palliative Care | volume = 17 | issue = 1 | pages = 114 | date   = October 2018 | pmid = 30305068 | pmc = 6180419 | doi = 10.1186/s12904-018-0367-4 | doi-access = free }}</ref> However, one study looking at insights into Chinese perspectives on DNR showed that the majority of DNR orders in Taiwan were signed by surrogates.<ref>{{Cite journal|last=Blank|first=Robert H.|date=May 2011|title=End-of-Life Decision Making across Cultures|url=http://journals.sagepub.com/doi/10.1111/j.1748-720X.2011.00589.x|journal=The Journal of Law, Medicine & Ethics|volume=39|issue=2|pages=201–214|doi=10.1111/j.1748-720X.2011.00589.x|pmid=21561515|s2cid=857118|issn=1073-1105}}</ref> Typically doctors discuss the issue of DNR with the patients family rather than the patient themselves.<ref name=":0" /> In Taiwan, there are two separate types of DNR forms: DNR-P which the patient themselves sign and DNR-S in which a designated surrogate can sign. Typically, the time period between signing the DNR and death is very short, showing that signing a DNR in Taiwan is typically delayed. Two witnesses must also be present in order for a DNR to be signed.<ref name=":0">{{Cite journal|last1=Wen|first1=Kuei-Yen|last2=Lin|first2=Ya-Chin|last3=Cheng|first3=Ju-Feng|last4=Chou|first4=Pei-Chun|last5=Wei|first5=Chih-Hsin|last6=Chen|first6=Yun-Fang|last7=Sun|first7=Jia-Ling|date=September 2013|title=Insights into Chinese perspectives on do-not-resuscitate (DNR) orders from an examination of DNR order form completeness for cancer patients|url= |journal=Supportive Care in Cancer|volume=21|issue=9|pages=2593–2598|doi=10.1007/s00520-013-1827-2|issn=0941-4355|pmc=3728434|pmid=23653012}}</ref>

DNR orders have been legal in Taiwan since June 2000 and were enacted by the Hospice and Palliative Regulation. Also included in the Hospice and Palliative Regulation is the requirement to inform a patient of their terminal condition, however, the requirement is not explicitly defined leading to interpretation of exact truth telling.<ref name=":0" />

=== United Arab Emirates ===
The [[UAE]] have laws forcing healthcare staff to resuscitate a patient even if the patient has a DNR or does not wish to live. There are penalties for breaching the laws.<ref>{{cite web|url=http://www.thenational.ae/news/uae-news/courts/nurses-deny-knowledge-of-do-not-resuscitate-order-in-patients-death|title=Nurses deny knowledge of 'do not resuscitate' order in patient's death | first = Salam | last = Al Amir | name-list-style = vanc |date= 25 September 2011 |work =  The National | location = United Arab Emirates |access-date=12 April 2018}}</ref>

=== United Kingdom ===

==== England ====
In [[England]], CPR is presumed in the event of a [[cardiac arrest]] unless a ''do not resuscitate'' order is in place. If they have capacity as defined under the [[Mental Capacity Act 2005]] the patient may decline resuscitation. Patients may also specify their wishes and/or devolve their decision-making to a proxy using an [[advance directive]], which are commonly referred to as '[[Living Wills]]', or an emergency care and treatment plan (ECTP), such as ReSPECT. Discussion between patient and doctor is integral to decisions made in advance directives and ECTPs, where resuscitation recommendations should be made within a more holistic consideration of all treatment options.<ref name="RCUK Patients" /> Patients and relatives cannot demand treatment (including CPR) which the doctor believes is futile and in this situation, it is their doctor's duty to act in their 'best interest', whether that means continuing or discontinuing treatment, using their clinical judgment. If the patient lacks capacity, relatives will often be asked for their opinion in order to form a 'best interest' view of what the individual's views would have been (prior to losing capacity). Evaluation of ReSPECT (an ECTP) found that resuscitation status remained a central component of conversations, and that there was variability in the discussion of other emergency treatments.<ref name="Eli 2020" />
[[File:Scotland DNACPR - obverse.png|thumbnail|upright=1.8|DNACPR form as used in Scotland]]

In 2020 the [[Care Quality Commission]] found that residents of [[Nursing home|care homes]] had been given inappropriate orders of Do not attempt cardiopulmonary resuscitation (DNACPR) without notice to residents or their families, causing avoidable deaths.<ref name="car-g">{{Cite news |last=Booth |first=Robert |date=2020-12-03 |title='Do not resuscitate' orders caused potentially avoidable deaths, regulator finds |language=en |url=http://www.theguardian.com/society/2020/dec/03/do-not-resuscitate-orders-caused-potentially-avoidable-deaths-regulator-finds |access-date=2021-02-15}}</ref> In 2021, the [[Mencap]] charity found that people with learning disabilities also had inappropriate DNACPR orders.<ref name="mencap-g">{{Cite news |last=Tapper |first=James |date=2021-02-13 |title=Fury at 'do not resuscitate' notices given to Covid patients with learning disabilities |language=en |work=The Guardian |url=http://www.theguardian.com/world/2021/feb/13/new-do-not-resuscitate-orders-imposed-on-covid-19-patients-with-learning-difficulties |access-date=2021-02-15}}</ref> Medical providers have said that any discussion with patients and families is not in reference to consent to resuscitation and instead should be an explanation.<ref name="Resus Council Consent.">{{cite web |title=Decisions relating to cardiopulmonary resuscitation: A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing |url=http://www.resus.org.uk/pages/dnar.pdf |website=Resus.org.uk |publisher=Resuscitation Council (UK) |access-date=17 June 2014 |archive-date=19 March 2015 |archive-url=https://web.archive.org/web/20150319150953/http://resus.org.uk/pages/dnar.pdf |url-status=dead }}</ref> The UK's regulatory body for doctors, the General Medical Council, provides clear guidance on the implementation and discussion of DNACPR decisions,<ref>{{Cite web|title=Cardiopulmonary resuscitation (CPR)|url=https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life/cardiopulmonary-resuscitation-cpr|access-date=2021-09-15|website=www.gmc-uk.org|language=en}}</ref> and the obligation to communicate these decisions effectively was established by legal precedent in 2015.<ref>{{Cite web|title=DNACPR orders – advice and obligations|url=https://mdujournal.themdu.com:443/issue-archive/issue-5/dnacpr-orders-advice-and-obligations|access-date=2021-09-15|website=mdujournal.themdu.com|language=en}}</ref>

==== Scotland ====
In [[Scotland]], the terminology used is "Do Not Attempt Cardiopulmonary Resuscitation" or "DNACPR". There is a single policy used across all of [[NHS Scotland]]. The legal standing is similar to that in England and Wales, in that CPR is viewed as a treatment and, although there is a general presumption that CPR will be performed in the case of cardiac arrest, this is not the case if it is viewed by the treating [[clinician]] to be futile. Patients and families cannot demand CPR to be performed if it is felt to be futile (as with any medical treatment) and a DNACPR can be issued despite disagreement, although it is good practice to involve all parties in the discussion.<ref>{{cite web|title=Do Not Attempt Cardiopulmonary Resuscitation (DNACPR): Integrated Adult Policy |author=Scottish Government |publisher=NHS Scotland |date=May 2010|url=http://www.scotland.gov.uk/Resource/Doc/312784/0098903.pdf}}</ref>

As in England and Wales, inappropriate orders have been given to individuals who had no medical reason for them, such as a deaf man who received a DNACPR order in 2021 due to "communication difficulties."<ref>{{cite web|title=Deaf man given DNR order without his consent|date=4 June 2021|url=https://www.deafaction.org/news/deaf-man-given-dnr-order-without-his-consent/}}</ref>

==== Wales ====
[[Wales]] has its own national DNACPR policy, 'Sharing and Involving'.<ref>{{Cite web|title=Wales Sharing and Involving DNACPR Policy|url=https://wales.nhs.uk/DNACPR}}{{Dead link|date=February 2024 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> They use the term 'Do Not Attempt Cardiopulmonary Resuscitation' or 'DNACPR'. They also have an active public information campaigns, which includes the website 'TalkCPR' <ref>{{Cite web|title=Talk CPR Videos and Resources|url=https://talkcpr.wales|url-status=live|archive-url=https://web.archive.org/web/20160120164706/http://talkcpr.wales:80/ |archive-date=2016-01-20 }}</ref>

=== United States ===
In the United States the documentation is especially complicated in that each state accepts different forms, and [[advance directives]] also known as [[living wills]] may not be accepted by [[Emergency medical services|EMS]] as legally valid forms. If a patient has a living will that specifies the patient requests DNR but does not have a properly filled out state-sponsored form that is co-signed by a physician, EMS may attempt resuscitation.

The DNR decision by patients was first litigated in 1976 in ''[[In re Quinlan]]''. The New Jersey Supreme Court upheld the right of Karen Ann Quinlan's parents to order her removal from [[artificial ventilation]]. In 1991 Congress passed into law the [[Patient Self-Determination Act]] that mandated hospitals honor an person's decision in their healthcare.<ref name="The continuing ethical dilemma of the do-not-resuscitate order">{{cite news |title = The continuing ethical dilemma of the do-not-resuscitate order |url = http://findarticles.com/p/articles/mi_m0FSL/is_n4_v67/ai_20972811/ |access-date = 2009-08-23 |date = April 1998 |work = AORN Journal |quote = The right to refuse or terminate medical treatment began evolving in 1976 with the case of Karen Ann Quinlan v New Jersey (70NJ10, 355 A2d, 647 [NJ 1976]). This spawned subsequent cases leading to the use of the DNR order.(4) In 1991, the Patient Self-Determination Act mandated hospitals ensure that a patient's right to make personal health care decisions is upheld. According to the act, a patient has the right to refuse treatment, as well as the right to refuse resuscitative measures.(5) This right usually is accomplished by the use of the DNR order. | first=Evelyn | last=Eckberg | name-list-style = vanc }}</ref> Forty-nine states currently permit the next of kin to make medical decisions of incapacitated relatives, the exception being [[Missouri]]. Missouri has a Living Will Statute that requires two witnesses to any signed advance directive that results in a DNR/DNI code status in the hospital.

In the United States, [[cardiopulmonary resuscitation]] (CPR) and [[advanced cardiac life support]] (ACLS) will not be performed if a valid written DNR order is present. Many states do not recognize [[living wills]] or [[health care proxy|health care proxies]] in the prehospital setting and prehospital personnel in those areas may be required to initiate resuscitation measures unless a specific state-sponsored form is properly filled out and cosigned by a physician.<ref name="DO NOT RESUSCITATE – ADVANCE DIRECTIVES FOR EMS Frequently Asked Questions and Answers">{{cite news|title=DO NOT RESUSCITATE – ADVANCE DIRECTIVES FOR EMS Frequently Asked Questions and Answers |url=http://www.emsa.ca.gov/personnel/DNR_faq.asp |access-date=2009-08-23 |year=2007 |work=State of California Emergency Medical Services Authority |quote=# What if the EMT cannot find the DNR form or evidence of a MedicAlert medallion? Will they withhold resuscitative measures if my family asks them to? No. EMS personnel are taught to proceed with CPR when needed, unless they are absolutely certain that a qualified DNR advance directive exists for that patient. If, after spending a reasonable (very short) amount of time looking for the form or medallion, they do not see it, they will proceed with lifesaving measures. |url-status=dead |archive-url=https://web.archive.org/web/20090823161856/http://www.emsa.ca.gov/personnel/DNR_faq.asp |archive-date=2009-08-23 }}</ref><ref name="Frequently Asked Questions re: DNR's">{{cite news |title = Frequently Asked Questions re: DNR's |url =http://www.health.state.ny.us/nysdoh/ems/policy/99-10.htm |access-date = 2009-08-23 |date = 1999-12-30 |work = New York State Department of Health |quote = May EMS providers accept living wills or health care proxies? A living will or health care proxy is NOT valid in the prehospital setting  }}</ref>

==== Legal precedent for the right to refuse medical interventions ====
There are three notable cases which set the baseline for patient's rights to refuse medical intervention:

# [[Karen Ann Quinlan|Karen Quinlan]], a 21-year-old woman, was in a persistent vegetative state after experiencing two 15-minute apneic periods secondary to drug use. After a year without improvement her father requested that life support be withdrawn. The hospital refused and this culminated in a court case. The trial court sided with the hospital, however the New Jersey Supreme Court reversed the decision. This was the first of multiple state level decisions pre-empting the Cruzan case which established the non-religious (there were other prior rulings regarding Jehovah's Witnesses) right to refuse care and extended that right to incapacitated patients via their guardians. It also established that court cases are not needed to terminate care when there is concordance between the stakeholders in the decision (Guardian, Clinician, Ethics Committees). It also shifted the focus from the right to seek care to the right to die. Mrs. Quinlan survived for 9 years after mechanical ventilation was discontinued.<ref>{{Cite web|last=Tiegreen|first=Tim|title=Case Study - Matter of Quinlan|url=https://practicalbioethics.org/case-studies-study-guide-matter-of-quinlan.html|access-date=2021-09-12|website=Center for Practical Bioethics|language=en-gb}}</ref>
# [[Cruzan v. Director, Missouri Department of Health|Nancy Cruzan]] was a 31-year-old woman who was in a persistent vegetative state after a motor vehicle accident that caused brain damage. Her family asked that life support be stopped after 4 years without any improvement. The hospital refused without a court order, and the family sued to obtain one. The trial court sided with the family concluding that the state could not override her wishes. This ruling was appealed to and reversed by the Missouri Supreme Court. This case was ultimately heard by the United States Supreme Court, which affirmed the right of competent individuals to refuse medical treatment and established standards for refusal of treatment for an incompetent person.<ref>{{Cite web|title=Case Study - The Case of Nancy Cruzan|url=https://www.practicalbioethics.org/shared-decision-making-and-advance-care-planning/end-of-life-ethics/the-case-of-nancy-cruzan/|access-date=2022-12-05|website=Center for Practical Bioethics|date=3 November 2021 |language=en-gb}}</ref>
# [[Theresa Schiavo|Theresa "Terri" Schiavo]] was a 27-year-old woman who experienced cardiac arrest and was resuscitated successfully. She was in a persistent vegetative state thereafter. After 8 years in this state without recovery, her husband decided to have her feeding tube removed. Schiavo's parents disagreed and the case that ensued ultimately was heard by the Florida Supreme Court which ruled that remaining alive would not respect her wishes. The United States Supreme Court affirmed that decision and refused to hear the case. This case affirmed the right of a patient to refuse care that is not in their best interests even when incapacitated.<ref>{{Cite journal|last1=Hook|first1=C. Christopher|last2=Mueller|first2=Paul S.|date=2005-11-01|title=The Terri Schiavo Saga: The Making of a Tragedy and Lessons Learned|url=https://www.mayoclinicproceedings.org/article/S0025-6196(11)61439-0/abstract|journal=Mayo Clinic Proceedings|language=English|volume=80|issue=11|pages=1449–1460|doi=10.4065/80.11.1449|pmid=16295025|issn=0025-6196|doi-access=free}}</ref>