Do Not Resuscitate Manitoba: DNR Orders, Goals of Care Levels, and How They Work
How DNR Orders Work in Manitoba
A Do Not Resuscitate (DNR) order in Manitoba isn't a standalone document you fill out at home. It's a clinical order written by a physician or nurse practitioner within the healthcare system. The terminology Manitoba's health regions actually use is "Goals of Care designation" — a broader framework that includes DNR as one component but covers much more than just resuscitation preferences.
This distinction matters because many families assume they can simply write "DNR" on a document at home and that paramedics will follow it. That's not how it works. A Health Care Directive can express your preference to decline CPR, but the clinical order that binds healthcare providers is the Goals of Care form completed within the health region's system. Your directive informs that order — it doesn't replace it.
Manitoba's Three Goals of Care Levels
Manitoba's regional health authorities use a standardized three-level framework for clinical care orders. Each level translates general treatment preferences into specific medical instructions:
Level R — Resuscitative Care
Level R represents resuscitative care. It means the healthcare team uses appropriate resuscitative interventions, which may include attempted CPR, defibrillation, intubation, and transfer to intensive care.
Level R is appropriate for people who want every available medical treatment attempted regardless of the outcome, or for people with reversible conditions where aggressive treatment has a reasonable chance of restoring quality of life.
Level M — Medical Care
Level M authorizes medical investigations and treatments — antibiotics, IV fluids, imaging, hospital transfer — but excludes resuscitation. If the patient's heart stops or they stop breathing, CPR will not be attempted. This is the level most people mean when they think about a "DNR."
Level M is appropriate for people with serious illness who want active treatment for treatable complications (like infections or dehydration) but have decided that CPR — with its statistically low success rate for elderly or seriously ill patients and its high likelihood of causing broken ribs, brain damage, or prolonged ICU dependency — isn't aligned with their goals.
Level C — Comfort Care
Level C focuses exclusively on comfort, symptom control, and dignity. No resuscitation, no medical investigations aimed at diagnosis or cure, no hospital transfers for treatment. Pain medication, anti-nausea drugs, oxygen for comfort, and emotional and spiritual support are the core interventions.
Level C is appropriate for patients in the final phase of a terminal illness who want to die peacefully without medical interventions that would extend the dying process rather than improve quality of life.
How Your Advance Directive Connects to Goals of Care
Your Health Care Directive documents your general preferences. The Goals of Care form translates those preferences into active medical orders. Here's how they connect:
You create a Health Care Directive documenting your treatment preferences and naming a proxy. You might write: "If I have a terminal condition with no reasonable prospect of recovery, I do not want CPR, mechanical ventilation, or transfer to ICU. I want comfort-focused care."
When you're admitted to a care facility or hospital, the clinical team reviews your directive and has a conversation with you (or your proxy, if you've lost capacity) about Goals of Care. They'll ask questions that map your preferences to their C/M/R framework.
The physician writes a Goals of Care order that reflects your wishes. This order goes into your medical chart and is immediately actionable by any healthcare provider who encounters you.
If you're receiving care at home, the Goals of Care form should also be in your ERIK (Emergency Response Information Kit) on the refrigerator. Paramedics responding to a 911 call look for this kit — and the Goals of Care designation inside it tells them whether to attempt resuscitation or provide comfort care.
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The Problem With Not Having These Conversations
Without a Health Care Directive and a corresponding Goals of Care order, your wishes may not be available as an active clinical order during an emergency. This can mean:
- Paramedics may not have an active Goals of Care designation to guide a home response
- Emergency physicians may need to make treatment decisions without your documented guidance
- Your family may face urgent decisions about treatment without a clear record of what you would want
CPR itself is often poorly understood. For elderly patients with serious underlying conditions, the survival-to-discharge rate after in-hospital cardiac arrest is roughly 10-20%, and significantly lower for out-of-hospital arrest. Among those who survive, a substantial percentage experience neurological damage or significantly reduced quality of life. These statistics don't make CPR wrong — they make it a decision that deserves deliberate, informed consideration rather than happening by default because no one documented an alternative.
How to Get a Goals of Care Order
You can't fill out a Goals of Care form yourself — it requires a healthcare provider. But you can initiate the conversation:
- Talk to your family physician about your resuscitation preferences and ask them to complete a Goals of Care designation
- During any hospital admission or personal care home intake, the clinical team will typically raise the Goals of Care conversation — be prepared with your preferences
- If you're receiving palliative care, the palliative care team will coordinate Goals of Care as part of their standard assessment
The Health Care Directive is what you control. The Goals of Care order is what the healthcare system generates from your directive. Both need to exist for your wishes to be followed consistently across settings — in hospital, in a personal care home, and at home during a paramedic response.
The Manitoba Advance Directive & Living Will Kit includes a Goals of Care reference sheet that maps treatment scenarios to the C/M/R framework, helping you articulate your preferences in language that translates directly into clinical orders.
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