What you need to know about Ontario's DNR rules

A CBC News investigation is raising questions about do-not-resuscitate protocol in Canada and Ontario's lack of database for DNR documents. ​Judy Nairn, the executive director of Hospice Waterloo Region, explains what happens if you sign a Do Not Resuscitate Confirmation Form and how it's used by doctors, nurses and paramedics.

Don't think of DNR as killing someone, but instead allowing them to die a natural death

In Ontario a doctor may not take a DNR order from a piece of paper. They must have a conversation with the patient or their appointed spokesperson, said Judy Nairn. (Martin Barraud/Getty Images)

A CBC News investigation is raising questions about do-not-resuscitate protocol in Canada and Ontario's lack of a database for DNR documents, which has prompted 67-year-old Shahnaz Azarbehi of Toronto to wear the documents in a pouch around her neck. 

The Morning Edition's host Craig Norris spoke with ​Judy Nairn, executive director of Hospice Waterloo Region, to get a more complete picture of what happens if you sign a DNR form and how it's used by doctors and paramedics. 

The interview has been edited for length and clarity.

Craig Norris: What is the purpose of a DNR confirmation form?

Judy Nairn: I suppose in some ways the order could be phrased as "allow a natural death" rather than "do not resuscitate." What it does, is it's intended to restart the heart after your heart stops. In the case of DNR orders, they're usually directed to the paramedics who are coming into the house after a heart attack, a stroke, an accident, a scene out on the highway somewhere, and they are trying to stabilize a patient and get them to a hospital or to a medical practitioner. At that point, the medical practitioner takes over and treatment care plans are put in place. 

CN: Why would a person want one?

JN: Often it's because if someone is quite ill — or if they've had a very massive physical injury and they are resuscitated back — they are often worried that they would be put on life support; artificially kept alive when they don't want to be kept alive, where they would have no quality of life. And so the feeling is, if they have a do not resuscitate order they would be pre-empting that. They would have more control over what their existence would be like afterwards.
Shahnaz Azarbehi of Toronto wears her do-not-resuscitate request around her neck. She has learned that Ontario has no central registry where her wishes are recorded. (CBC)

Resuscitation can be quite an invasive procedure. It involves a lot of chest compressions, a lot of very physical activity. So if you are of failing health and you're kind of frail, it can be quite harmful to do resuscitation. 

It's not like television, they don't just pop up again. [There could be] broken bones ... there could be some brain damage because of lack of oxygen. I think it has a bit of a cachet that automatically means you would be fine. 

Often people feel a do not resuscitate order is like killing someone, but it's not. It's actually preventing further injury.

CN: How does Ontario's system of issuing DNRs differ from other provinces?

JN: I think people have misconceptions. The DNR does come with a serial number on it, but that's because a physician must issue it or sign it — or a regulated health professional, a nurse, can sign as well. So you can go on the web, you can see what a DNR looks like but you couldn't download it and print it yourself because they want to ensure it's a medical confirmation. So that's why they're serial numbered. 

A national registry really wouldn't do much because paramedics and firefighters, if they're in an accident scene, if they're in your home, they do not have time to look for [one]. Even patients that are home with a life-limiting illness will have a binder or an order form and they will be told "put it on your fridge" because that's where paramedics will look first, they'll look on the fridge.

CN: The DNR-C form is just part of the discussion that people should be having before they near the end of life. What else should we be talking about? 

JN: When I read the article about the lady in Toronto who was so concerned, I felt very bad for her because a lot of it is about not understanding how the medical system works, particularly in Ontario. 

So a lot of television and a lot of newspaper and written media are talking about "advanced directives" and about people trying to control their treatment choices as they approach end of life. And in Ontario, it's very different. In Ontario a doctor may not take an order from a piece of paper. They must have a conversation with the patient, and if the patient can't speak, they have to have a conversation with what's called the "substitute decision maker." And that substitute decision maker makes the decision on behalf of the patient as to what the patient would want. 

So after you've been stabilized after this accident and your DNR has not been used, when you get to the hospital the doctor who will be prescribing the treatment, or the options — which may put you on life support, or may not — has to get permission to do that from you or your substitute decision maker. 

CN: When should we start having these conversations?

JN: Right now. Over Thanksgiving dinner. Make sure you understand who in your family will make decisions for you if you can't or you're unconscious or you can't speak for yourself ... and do they know what you would want and will they make decisions based on what you would want.