Proposition for an international DNR symbol printable on patients’ wristbands and usable in hospital, nursing and retirement homes with the aim to avoid unwanted CPR in patients with a DNR status

The actual severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic highlights the need for advanced care planning (ACP) in patients affected with coronavirus disease of 2019 (COVID-19) in need for cardiopulmonary resuscitation (CPR) in case of sudden cardiac arrest (SCA).¹ Primary care physicians (PCP) and specialists with trust bonds with their patients should encourage completion of physician order for life-sustaining treatments (POLST) forms to respect one's wish in the face of death.¹ These official “Do Not Resuscitate (DNR)” codes are not always respected: a 9.42% rate of delivered CPR despite a DNR code (52 out of 552 SCA patients) was reported by the National Confidential Enquiry into Patient Outcome and Death in 2012 in the UK. Another study conducted in 2014 in an older and frailer patient population in the UK reported an outcome of 6.06% (8 out of 132 SCA patients).2, 3, 4

Reasons for unwanted CPR (uCPR) consist of absence of recording of patient's DNR status in nurses’ notes, of DNR decision discussions with patient and relatives in medical files and failure to communicate the patient's wish between teams.2, 3 Resuscitation teams arriving at the in-hospital setting, the emergency department, in homes, at home or on the street, generally do not know the patient and start immediately upon arrival after checking for absence of responsiveness and normal breathing.²

Here, we explore the idea of an international symbol printable on patients’ wristbands next to their personal identification, without using any acronym and making it usable everywhere (Fig. 1 ). The universal “STOP” symbol is drawn over a heart receiving CPR and/or defibrillation. It would be important to foresee a plastic flap with a pression button to cover the symbol to respect patient's privacy. The bracelet should not be easily removable as to not be exchanged between people.⁵ This idea could also be extended to nursing and retirement homes. The latter house elder populations where DNR codes should be known for each inhabitant. This could also be applied to each person chosing for DNR, independable of their actual health condition. Upon hospital intake, the symbol should be printed based on the global medical record (GMR) as established by the PCP. If the DNR code is established in-hospital by a medical doctor, the GMR should be updated, automatically informing the PCP and a new bracelet should be foreseen. This procedure could also be considered in nursing and retirement homes. For DNR codes in the general population (elderly living in their own house for example), this bracelet could be provided by the PCP. These combined strategies could help reduce the amount of uCPRs.

Fig. 1.

Proposition for an international DNR symbol printable on patients’ wristbands.

Implementation could be discussed by the International Liaison Committee on Resuscitation (ILCOR), the European Resuscitation Council (ERC), the American Heart Association (AHA) and all other resuscitation organisations wordwide, in a meeting between world specialists in the field with medical ethical and law specialists to avoid any misuse, exploring potential ethical grey zones and discussing solutions.⁵

Credit attribution

Part of the visuals were purchased from Shutterstock.com.

Funding

None.

Authorship

The authors made contributions to all of the following: (1) drafting the article or revising it critically for important intellectual content, (2) final approval of the version to be submitted.

Conflicts of interest

None.