EXECUTIVE SUMMARY

Clinicians sometimes assume DNR status means a preference for comfort measures only, but this is not necessarily the case.

• Such orders indicate only that the patient does not wish to receive CPR in the event of cardiac arrest.

• How code status is addressed for hospitalized patients is patient-specific.

• Healthcare providers can discover patient preferences only with a shared decision-making process.


An urgent request for an ethics consult recently came in from a nurse manager, who was distressed because an attending physician ordered continuous positive airway pressure (CPAP) for a do not resuscitate (DNR) patient.

“The patient received the CPAP per the physician order. There was a need to have a conversation with the nurse and team that ‘DNR’ does not mean ‘do not treat,’” says Mathew David Pauley, JD, MA, MDR, a regional ethicist at Kaiser Permanente Northern California in Oakland.

The nurse believed the patient’s DNR status indicated the patient did not wish to receive any treatments, but this was not the case. “Often, attitudes and approaches toward patients with DNR lean toward ‘this person is comfort measures only,’ when the person is not,” says Pauley.

Providers often tell patients or surrogates, “DNR does not mean ‘do not treat’” to allay concerns that DNR will result in someone getting no further treatment. “That said, often from the healthcare provider side, DNR does mean do not treat,” says Pauley.

When DNR patients are going into surgery, many clinicians assert that patients must be full code throughout the perioperative process. “This can create a number of issues and problems,” says Pauley. “Every institution I have worked at allowed patients to remain DNR for procedures.”

Helping both clinicians and patients understand the person’s code status is helpful. “The 92-year-old man who we emphatically educated to be DNR because of how frail he is, remains as frail, and at the same risk of harm, when he goes in for his ortho procedure,” says Pauley.

DNR also does not mean airway issues should not be addressed, adds Pauley: “If one is DNR and is also choking on a peach slice, the medical team should be actively trying to clear that person’s airway.”

Residents appear to assume that patients who would refuse CPR would prefer not to receive other interventions, found a recent study.1 Researchers surveyed 533 internal medicine residents, asking what interventions they would pursue for various clinical scenarios. Key findings include the following:

• decisions to intubate or perform CPR were largely dictated by patient code status;

• decisions to deliver noninvasive interventions such as medications, blood cultures, or imaging were largely unaffected by code status;

• decisions to pursue aggressive or invasive options (dialysis, bronchoscopy, surgical consultation, or transfer to the ICU) differed significantly based on code status.

Without explicit clarification of the patient’s goals of care, potentially beneficial care may be withheld against the patient’s wishes, the researchers concluded.

“A patient preference against CPR does not entail a preference against other invasive treatments. It requires a conversation,” says Paul Hutchison, MD, MA, assistant professor in the division of pulmonary and critical care medicine at Loyola University Chicago’s Stritch School of Medicine in Maywood, IL.

A patient with a DNR order who goes into shock may still want a central line and vasopressors, necessitating ICU care. Under the mistaken belief that a DNR order means a preference for comfort measures only, some clinicians won’t admit a DNR patient presenting to the ED to the ICU. “The patient shouldn’t necessarily be denied treatment in the ICU merely because of these orders,” says Hutchison.

All the do not intubate (DNI) or DNR order indicates is that the patient does not favor receiving those particular medical treatments in the case of either a cardiac arrest or respiratory failure.

“The ICU offers opportunities for various other forms of treatment that still may benefit the patient,” explains Hutchison.

When hospitalized patients are asked about their code status, typically the question focuses on intubation and CPR. In contrast, Physician Orders for Life-sustaining Treatment (POLST) forms typically specify whether the patient wants full treatment, selected treatments, or comfort measures only.

“The Patient Self-Determination Act says only that patients need to be asked if they have an advance directive and are to be provided one if they wish,” notes Hutchison. There is no requirement to obtain a code status.

“For a lot of admitted patients, asking about code status may actually have some detrimental effects,” says Hutchison. For instance, a conversation about code status with a young, healthy person coming in for an elective procedure could negatively affect trust between the patient and the hospital.

On the other hand, for patients at high risk for decompensation and death, there’s an opportunity to increase the number of advance directives completed for inpatients. “It should be a patient-by-patient determination,” says Hutchison. A one-size-fits-all approach is not feasible for hospital patients of varying ages, with varying levels of illness and varying preferences.

“How we address code status and advance directives with any given patient is completely dependent upon who the patient is and the clinical context,” says Hutchison.

Healthcare providers are “called upon, ethically and clinically, to get it right for our patients — especially in writing orders with high-stakes implications,” says Kathy Johnson Neely, MD, MA, medical director of the medical ethics program at Northwestern Memorial Hospital in Chicago.

DNR orders should be written only as the outcome of a shared decision-making process, says Neely: “The patient or surrogate brings to the table their values, goals, and limitations.” Healthcare providers bring expertise regarding the patient’s medical condition and options for care. This includes risk, benefit, burden, and anticipated outcomes as they would play out in various clinical contexts.

When healthcare providers engage in a shared decision-making discussion concerning cardiopulmonary arrest, says Neely, “we present them with a fork in the road.” There are only two options with very different treatment plans and hoped-for outcomes: attempting resuscitation, or allowing natural death with palliative interventions only.

“Healthcare providers must clearly recognize that a DNR order addresses only the pathophysiologic condition of cardiopulmonary arrest, and that a DNR order takes off the table only the package deal of interventions we know as CPR,” says Neely, adding that a DNR order does not preclude intubation for reasons other than cardiopulmonary arrest. Appending a DNI order in a unilateral fashion presents “a serious clinical and ethical breech of shared decision-making,” says Neely. Similarly, a DNR decision of itself does not preclude cardioversion for arrhythmia (other than ventricular fibrillation or pulseless ventricular tachycardia) or noninvasive positive pressure ventilation.

“The only way to elicit whether there are other interventions the patient would not want under any circumstances is to continue the shared decision-making conversation,” says Neely.

Thoughtful, thorough discussions are especially important when completing a POLST document with a patient, as these travel with the patient to any future healthcare setting. “We need to get it right for the long-term plan our colleagues may implement in the future, as well as our immediate care of the patient,” says Neely.

A patient with metastatic cancer with a DNR order might wish to eliminate any burdensome, life-prolonging interventions, taking intubation, ICU-level of care, and electrocardioversion entirely off the table. Alternatively, that same patient might want a time-limited trial of intubation; for example, if somnolent after a seizure for airway support, or in the context of exacerbation of COPD.

On the other hand, a frail, elderly patient living alone might have a DNR order, wanting no resuscitation attempted if she is found down at home — but falls and fractures her femur. “In this unanticipated context, she might or might not agree with rescinding her DNR,” says Neely.

Continued treatment of a patient with a DNR order should be the default, says Kathy Kinlaw, associate director of the Emory University Center for Ethics in Atlanta. This is the case whether the patient enters the hospital with a pre-existing DNR order from a long-term care facility, or a DNR order is entered during the hospitalization.

“The organizational culture of care needs to educate and reinforce these distinctions with multidisciplinary team members involved with resuscitation decisions and caring for patients dealing with serious or critical illness,” says Kinlaw.

In academic settings, team rounds should not be omitted for patients with DNR orders, adds Kinlaw: “There is much to learn from these patients and families.” Patient monitoring should also continue; medications, central lines, specialty consultation, transfer to intensive care, and surgery may all be appropriate for DNR patients.

“Provision of indicated treatment for the patient should be assumed, unless an explicit conversation addresses the question of forgoing of other treatments,” says Kinlaw. Clinical ethicists can play an important part in clarifying this point. This can be done with conversations on the floor to educate and reinforce what DNR decisions entail — and what they don’t entail.

“This is true in ethics consultations with particular patients and families, but also proactively, in shifting the practice in units where DNR decisions are frequent,” says Kinlaw.

Such early ethics intervention can even change the way in which initial resuscitation conversations proceed. “This enhances understanding for clinical team members, patients, and families from the start,” says Kinlaw.

REFERENCE

1. Stevenson EK, Mehter HM, Walkey AJ, et al. Association between do not resuscitate/do not intubate status and resident physician decision-making: A national survey. Ann Am Thorac Soc 2017; 14(4):536-542.

SOURCES

• Paul Hutchison, MD, MA, Assistant Professor, Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Stritch School of Medicine, Maywood, IL. Phone: (708) 216-0461. Email: Paul.Hutchison@lumc.edu.

• Kathy Kinlaw, Associate Director, Center for Ethics, Emory University, Atlanta. Email: kkinlaw@emory.edu.

• Kathy Johnson Neely, MD, MA, Medical Director, Medical Ethics Program, Northwestern Memorial Hospital, Chicago. Phone: (312) 694-2578. Email: k-neely@northwestern.edu.

• Mathew David Pauley, JD, MA, MDR, Regional Ethicist, Kaiser Permanente Northern California, Oakland. Phone: (510) 987-4608. Email: mathew.d.pauley@kp.org.