documents written by individuals themselves, so as to state their wishes for care, if they are no longer able to speak for themselves. in contrast, it is a physician or hospital staff member who writes a dnr "physician's order," based upon the wishes previously expressed by the individual in their advance directive or living will. similarly, at a time when the individual is unable to express their wishes, but has previously used an advance directive to appoint an agent, then a physician can write such a dnr "physician's order" at the request of that individual's agent. these various situations are clearly enumerated in the "sample" dnr order presented on this page. it should be stressed that, in the united states, an advance directive or living will is not sufficient to ensure a patient is treated under the dnr protocol, even if it is their wish, as neither an advance directive nor a living will legally binds doctors. they can be legally binding in appointing a medical representative, but not in treatment decisions. physician orders for life-sustaining treatment (polst) documents are the usual place where a dnr is recorded outside hospitals. a disability rights group criticizes the process, saying doctors are trained to offer very limited scenarios with no alternative treatments, and steer patients toward dnr. they also criticize that dnr orders are absolute, without variations for context. the mayo clinic found in 2013 that "most patients with dnr/dni orders want cpr and/or intubation in hypothetical clinical scenarios," so the patients had not had enough explanation of the dnr/dni or did not understand the explanation. in the uk, emergency care and treatment plans (e.g. respect) are clinical recommendations written by healthcare professionals after discussion with patients or their relatives about their priorities of care. research has found that the involvement of patients or their family in forming ectp recommendations is variable. in some situations (where there are limited treatment options available, or where the patient is likely to deteriorate quickly) healthcare professionals will not explore the patient's preferences, but will instead ensure that patients or their relatives understand what treatment will or will not be offered. medical jewellery medical bracelets, medallions, and wallet cards from approved providers allow for identification of dnr patients outside in home or non-hospital settings. each state has its own dnr policies, procedures, and accompanying paperwork for emergency medical service personnel to comply with such forms of dnr. dnr tattoos there is a growing trend of using dnr tattoos, commonly placed on the chest, to replace other forms of dnr, but these often cause confusion and ethical dilemmas among healthcare providers. laws vary from state to state regarding what constitutes a valid dnr and currently do not include tattoos. end of life (eol) care preferences are dynamic and depend on factors such as health status, age, prognosis, healthcare access, and medical advancements. dnr orders can be rescinded while tattoos are far more difficult to remove. at least one person decided to get a dnr tattoo based on a dare while under the influence of alcohol. ethics and violations dnr orders in certain situations have been subject to ethical debate. in many institutions it is customary for a patient going to surgery to have their dnr automatically rescinded. though the rationale for this may be valid, as outcomes from cpr in the operating room are substantially better than general survival outcomes after cpr, the impact on patient autonomy has been debated. it is suggested that facilities engage patients or their decision makers in a 'reconsideration of dnr orders' instead of automatically making a forced decision. when a patient or family and doctors do not agree on a dnr status, it is common to ask the hospital ethics committee for help, but authors have pointed out that many members have little or no ethics training, some have little medical training, and they do have conflicts of interest by having the same employer and budget as the doctors. in the united states there is accumulating evidence of racial differences in rates of dnr adoption. a 2014 study of end stage cancer patients found that non-latino white patients were significantly more likely to have a dnr order (45%) than black (25%) and latino (20%) patients. the correlation between preferences against life-prolonging care and the increased likelihood of advance care planning is consistent across ethnic groups. there are also ethical concerns around how patients reach the decision to agree to a dnr order. one study found that patients wanted intubation in several scenarios, even when they had a do not intubate (dni) order, which raises a question whether patients with dnr orders may want cpr in some scenarios too. it is possible that providers are having a "leading conversation" with patients or mistakenly leaving crucial information out when discussing dnr. one study reported that while 88% of young doctor trainees at two hospitals in california in 2013 believed they themselves would ask for a dnr order if they were terminally ill, they are flexible enough to give high intensity care to patients who have not chosen dnr. there is also the ethical issue of discontinuation of an implantable cardioverter defibrillator (icd) in dnr patients in cases of medical futility. a large survey of electrophysiology practitioners, the heart specialists who implant pacemakers and icds, noted that the practitioners felt that deactivating an icd was not ethically distinct from withholding cpr thus consistent with dnr. most felt that deactivating a pacemaker was a separate issue and could not be broadly ethically endorsed. pacemakers were felt to be unique devices, or ethically taking a role of "keeping a patient alive" like dialysis. a self-report study from 1999 conducted in germany and sweden found that the frequency of resuscitations performed against patients' wishes (per dnr status) was as high as 32.5% among german doctors polled. violations and suspensions medical professionals can be subjected to ramifications if they are aware of a dnr. each state has established laws and rules that medical providers must follow. for example, in some states within the us, dnrs only apply within a hospital, and can be disregarded in other settings. in these states, emts can therefore administer cpr until reaching the hospital where such laws exist. if a medical professional knows of a dnr and continues with resuscitation efforts, then they can be sued by the family of the patient. this happens often, with a recent jury awarding $400,000 to the family of a patient for "wrongful prolongation of life" in june 2021. physicians and their attorneys have argued in some cases that when in doubt, they often err on the side of life-saving measures because they can be potentially be reversed later by disconnecting the ventilator. this was the case in 2013 when beatrice weisman was wrongfully resuscitated, leading to the family filing a lawsuit. bystanders who are not healthcare professionals working in a professional setting are protected under the good samaritan law in most cases. bystanders are also protected if they begin cpr and use a aed even if there is a dnr tattoo or other evident indicator. instead of violating a dnr, anesthesiologist often require suspension of a dnr during palliative care surgeries, such as when a large tumor needs to be removed or a chronic pain issue is being solved. anesthesiologists argue that the patient is in an unnatural state during surgery with medications, and anesthesiologists should be allowed to reverse this state. this suspension can occur from during the pre-op, peri-op, and post-operative period. these suspensions used to be automatic and routine, but this is now viewed as unethical. the patient self-determination act also prohibits this, as automatic suspension would be a violation of this federal order. however, it is still a common practice for patients to opt for a suspension of their dnr depending on the circumstances of the surgery. ethical dilemmas on suspending a dnr occur when a patient with a dnr attempts suicide and the necessary treatment involves ventilation or cpr. in these cases, it has been argued that the principle of beneficence takes precedence over patient autonomy and the dnr can be revoked by the physician. another dilemma occurs when a medical error happens to a patient with a dnr. if the error is reversible only with cpr or ventilation there is no consensus if resuscitation should take place or not. terminology dnr and do not resuscitate are common terms in the united states, canada, and new zealand. this may be expanded in some regions with the addition of dni (do not intubate). dni is specific for not allowing the placement of breathing tubes. in some hospitals dnr alone will imply no intubation, though 98% of intubations are unrelated to cardiac arrest; most intubations are for pneumonia or surgery. clinically, the vast majority of people requiring resuscitation will require intubation, making a dni alone problematic. hospitals sometimes use the expression no code, which refers to the jargon term code, short for code blue, an alert to a hospital's resuscitation team. if a patient does want to be resuscitated, their code status may be listed as full code (the opposite of dnr). if the patient only wants to be resuscitated under certain conditions, this is termed partial code. some areas of the united states and the united kingdom include the letter a, as in dnar, to clarify "do not attempt resuscitation". this alteration is so that it is not presumed by the patient or family that an attempt at resuscitation will be successful. as noted above in less care for dnr patients, the word "resuscitation" has grown to include many treatments other than cpr, so dnr has become ambiguous, and authors recommend "no cpr" instead. in the united kingdom the preferred term is now dnacpr, reflecting that resuscitation is a general term which includes cardiopulmonary resuscitation as well as, for example, the administration of intravenous fluid. since the term dnr implies the omission of action, and therefore "giving up", a few authors have advocated for these orders to be retermed allow natural death. others say and is ambiguous whether it would allow morphine, antibiotics, hydration or other treatments as part of a natural death. new zealand and australia, and some hospitals in the uk, use the term nfr or not for resuscitation. typically these abbreviations are not punctuated, e.g., dnr rather than d.n.r. resuscitation orders, or lack thereof, can also be referred to in the united states as a part of physician orders for life-sustaining treatment (polst), medical orders for life-sustaining treatment (molst), physician's orders on scope of treatment (post) or transportable physician orders for patient preferences (tpopp) orders, typically created with input from next of kin when the patient or client is not able to communicate their wishes. another synonymous term is "not to be resuscitated" (ntbr). in 2004 the internal telephone number for cardiac arrests in all uk hospitals was standardised to 2222; in 2017 the european board of anaesthesiology (eba, european resuscitation council (erc), and the european society of anaesthesiology (esaic) issued a joint statement recommending this practice across all european hospitals. current uk practice is for resuscitation recommendations to be standalone orders (such as dnacpr) or embedded within broader emergency care and treatment plans (ectps), such as the recommended summary plan for emergency care and treatment (respect). 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?" 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. doctors' approaches to communication about resuscitation country/locationdiscuss with patient or familytell other doctors the decision argentinamostwritten australiamost, halforal+notes+pre-printed,(2) notes austriahalfnotes barbadoshalforal+notes belgiumhalf, rarelynotes+electronic brazilmostoral+notes bruneirarelyoral+notes canadaalways, mostoral+notes, oral+notes+electronic, notes+pre-printed colombiahalforal cubaalwaysoral denmarkmostelectronic francemostpre-printed, germanyalwaysoral+notes+electronic hong kongalways, halfnotes+pre-printed, oral+notes+pre-printed hungaryrarelyoral icelandrarelynotes+electronic indiaalwaysnotes, oral, oral+notes irelandmost, rarelynotes