Editing Do not resuscitate (section)

=== 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>