“It is a sad state that fear of liability will oftentimes negate the moral choice made by a terminally ill patient.”
– Journal of Air Law and Commerce

Background

In August 2024, I gave a presentation, “You’re suing me because I kept your mom alive? Avoiding wrongful life lawsuits.” I discussed the consequences for medical staff when they disregard a valid DNR and revive a person, against their wishes. There are numerous nationwide lawsuits against doctors and others for overriding a patient’s DNR, violating their autonomy and patient rights. After my presentation, the owner of a non-emergency medical transport company, Flying Angels, asked me if DNRs must be followed while in flight. He claimed, and my research confirms, that the flight crew protocol is to ignore a DNR and try to resuscitate the person.

Legal authority to revive

No federal law or legal precedent grants airlines the right to follow or override a DNR. They do this due to legalities surrounding a mid-air medical emergency, including ambiguities in aviation law, no clear legal guidance, airline policy, flight deviation costs, safety concerns, and jurisdiction of state-specific DNRs. Here are two examples of the policy.

“Centers for Disease Control Yellow Book: Health information for international travel edition: 2026: If a traveler has a ‘DNR order, you may choose to heed this. Despite this documentation, be aware that individual airline policies might require flight attendants to attempt resuscitation.”

“Hawaiian Airlines in their contract of carriage: “We will not honor any ‘do not resuscitate’ order… your travel with us indicates your informed consent to be treated.”

I doubt many people are aware of the practice, let alone what I can only call a “weasel clause” hidden in a typical 100-plus-page travel contract, absolving airlines of liability. However, the validity and enforceability of such clauses are ethically complex. They may be challenged based on a lack of transparency, patient autonomy, and a person’s right to refuse even life-saving medical treatment, all established by federal and case law. The public is not “on board” with this policy. In a Flyer Talk article confirming the practice, What happens when someone dies on a flight many readers were outraged that airlines would ignore a valid DNR.

A pilot’s perspective

I interviewed a retired airline pilot about the issue. He confirmed that the captain and crew have ultimate authority and that CPR use is the protocol that overrides a DNR. However, he said if the person’s medical POA or family had valid documentation, he would not intervene with CPR, claiming, for him, it was a moral issue rather than a legal one. Keeping someone alive against their will when they had the document to prove it was their wish not to be saved would be an onerous burden for him to bear, even if the law was on his side.

Veteran honor flights

I was in Washington, D.C., waiting to board a flight when an Honor Flight arrived. Everyone in the gate area cheered as a group of veterans was guided off the plane, anticipating their three-day D.C. adventure. Many of these veterans were over 90 years old, and some were on oxygen, most in wheelchairs. I learned that one vet was in hospice, and this trip was his final wish. Given the airline’s policy, I asked Honor Flight Network if a veteran’s DNR would be honored.

Staff answered yes or no, depending on each hub and state laws. HFN’s 128 hubs in 46 states handle the DNR paperwork. Another program, the HFN Lone Eagle TLC flights (Their Last Chance), is for veterans with a verified terminal illness and prognosis of less than 12 months to live. Will their DNR be honored in flight? There is no definitive answer. CPR performed on someone frail or in poor health can cause severe medical trauma, including broken bones, damage to internal organs, or brain damage from lack of oxygen. CPR often does not work despite the best efforts, so why subject a veteran who has chosen DNR to the pain of CPR? While state-issued DNRs, or POLSTs, can help communicate the patient’s wishes on an aircraft, crew members are not legally mandated to follow these orders across state lines.

The need for reform

Medical first responders also have concerns about a lack of regulations for in-flight medical emergencies.

“The current system is a patchwork of policies, processes, and regulations highlighted by the global airline industry’s disarray, lack of universality, and limited standardization in managing in-flight emergencies. There is an identified need for universal cross-border regulations and an awareness of legal and ethical boundaries for medical responders on board commercial international aircraft.” Moral dilemmas of nurses during in-flight medical emergencies (Journal of Emergency Nursing, 2021)

Keys to having your DNR honored in flight

• Keep your properly documented and valid DNR or POLST readily accessible, especially if you have a condition that might result in cardiac arrest.
• Travel companions should know and advocate for the patient’s treatment preferences to first responders.
• If the crew wants to intercede with CPR, appeal to the captain, hoping he is ethical and understands patient rights.

Conclusion

Airlines have the power to change the protocol and honor verified DNRs. They can create guidance favoring the person with the DNR rather than automatically overriding their wishes. Agencies, like HFN, the Emergency Nursing Association, and others, can pressure airlines to adhere to patients’ rights. As with health care facilities and doctors, it will take time and may take a law or someone (or many someones) to sue, win, and set a legal precedent to change this misguided policy.

Althea Halchuck is a patient advocate.