Goals of Care Designation Newfoundland: DNR Orders and Medical Directives Explained

What DNR Actually Means in NL's Clinical System

Newfoundland and Labrador's healthcare system doesn't use a standalone "DNR order" the way many people imagine it — a single document that says "do not resuscitate" and nothing more. Instead, NL Health Services uses a Goals of Care Designation (GCD) framework that records one of three broad designations: Resuscitation (R), Medical Care (M), or Comfort Care (C). The attending clinician explains the scope of the selected order for the patient's situation.

Understanding these designations matters because your Advance Health Care Directive (AHCD) expresses your wishes in your own words, but the GCD order is what clinicians actually follow when making real-time treatment decisions.

The Three Designations

R — Resuscitation

This designation records a resuscitation-focused plan. Ask the attending clinician which interventions are covered by the order for your situation. In an emergency, absent documentation such as a Green Sleeve, paramedics may default to full resuscitation.

M — Medical Care

This designation records a medical-care plan. Ask the attending clinician which interventions are covered by the order for your situation.

C — Comfort Care

This designation records a comfort-care plan. Ask the attending clinician which treatments remain appropriate for symptom relief and which interventions are excluded in your situation.

How a GCD Order Gets Created

You can't write your own GCD order. It's a medical order issued by your attending physician or nurse practitioner based on a clinical conversation about your values, your medical situation, and your AHCD.

The typical process:

1. You complete your AHCD — documenting your treatment preferences and appointing a Substitute Decision Maker
2. You book a Goals of Care conversation with your physician — bring your AHCD to this appointment
3. Your physician reviews your directive alongside your current medical condition and discusses specific clinical scenarios with you
4. The physician issues a GCD order matching the designation that best reflects your wishes — R, M, or C
5. The GCD order enters your medical chart and is placed in your Green Sleeve for emergency access

This isn't a one-time event. Review your AHCD at least annually and after significant health or life changes, and ask your physician to review the GCD whenever your clinical situation or wishes change.

The Gap Between Your AHCD and the GCD

Your AHCD might say something like: "I do not want to be kept alive by machines if there is no reasonable chance of recovery." That's a valid expression of your wishes. But a paramedic responding to a cardiac arrest at 2 AM needs a binary answer — resuscitate or don't — and your AHCD is a multi-page legal document that takes time to locate, read, and interpret.

The GCD order closes this gap. It distills your complex, nuanced wishes into a standardized clinical order that helps clinicians act on the planned scope of care.

Without a GCD order, even a perfectly executed AHCD may not prevent interventions you didn't want. Paramedics are legally mandated to perform full resuscitation by default. The GCD order — particularly when stored in a visible Green Sleeve on your refrigerator — is what changes that default.

Common Misconceptions

"A DNR means they won't treat me at all." The label alone doesn't explain the whole GCD. Ask the physician or nurse practitioner who issues the order what treatment remains available under the selected designation and how it applies to CPR, hospital transfer, and symptom management.

"I can just tell the paramedics what I want." Verbal instructions aren't sufficient. Paramedics follow documented medical orders. If you're unconscious or confused when they arrive, verbal communication isn't possible anyway. The Green Sleeve containing your GCD order is what they're trained to look for.

"My AHCD is the same thing as a DNR." They serve different functions. Your AHCD is a legal document expressing your wishes. The GCD is a medical order issued by a physician. You need both. The AHCD provides the legal foundation; the GCD makes it clinically actionable.

"Once I have a C designation, I can't change my mind." While you still have capacity, you can discuss changed wishes with your physician and update your AHCD through one of the legal methods. Ask the clinician to review the GCD as well. The designation reflects your current wishes, not a permanent commitment.

Getting Your GCD in Place

If you have a completed AHCD but haven't yet spoken with your physician about a Goals of Care Designation, that conversation is the critical next step. The Newfoundland and Labrador Advance Directive & Living Will Kit includes specific conversation prompts for your GCD appointment and a Green Sleeve setup guide, so your legal wishes and clinical orders are aligned from the start.

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