Determine intent before following DNR orders

Patients’ wishes are not always as simple as what is written down

Patients with "do not resuscitate" orders present unique challenges for emergency physicians. "The main issue is discerning what the patient wants," says Gregory Larkin, MD, FACEP, director of research for the department of emergency medicine at Mercy Hospital in Pittsburgh and chair of the American College of Emergency Physicians’ (ACEP) ethics committee.

In general, err on the side of treating the patient, says Larkin. "If you’re unsure of patient wishes, you generally proceed with the resuscitation; however, if it becomes clear they never would have wanted resuscitative measures, or if they view such measures as unduly burdensome, then you withdraw."

First, it’s a mistake to operate on the assumption that all patients can be resuscitated, says Larkin. "It should really be called, ‘Do not attempt to resuscitate,’ you’re not going to resuscitate most people anyway. Everyone in medicine knows resuscitation rates are maybe 5% on a good day and around 1% in most big studies."

Most of the time efforts are unsuccessful, and frequently those patients who recover aren’t fully functioning. "You may have gotten their heart beating again, but the brain is really what defines us, and resuscitating the brain is far more challenging," says Larkin. "The brain can be isoelectric and yet the heart can be pumping mightily. CPR isn’t always the best care for vegetative patients."

Certain situations are especially hard for ED nurses and physicians. "A very difficult situation is when a patient comes in after the paramedic has intubated them in the field, and you come to find out that patient didn’t want to be intubated or resuscitated, and they didn’t know that in the field," says Christine Dimitrakopolous, MS, RN, MICN, current president of the California Emergency Nurses Association and an ethics consultant for the Emergency Nurses Association, based in Park Ridge, IL.

It’s not an ethical problem, because withdrawal of life support, including intubation, is no different from withholding it, says Dimitrakopolous. "The problem is psychological because it’s much harder to take something away you’ve already given them, knowing it could end their life, than to decide not to do it in the first place," she explains.

Another challenge is patients refusing life-saving interventions that have a good possibility of working. "We can’t determine what’s in their best interest, only they can," says Dimitrakopolous. "It’s very difficult for the health care provider to stand by and not impose their own judgement, but patients may have their own reasons for refusing treatment."

Another gray area comes if the family isn’t in agreement about the patient’s wishes, when the patient hasn’t put their wishes in writing. "You have no obligation to provide futile care, but otherwise it’s a problem, especially when it’s not a faraway cousin in Nebraska, but the husband and daughter who disagree," says Dimitrakopolous. "Very often what we do in the ED is abdicate the decision and treat, and send them up to the ICU with the assumption that you preserve life and it gives you time to look at the big picture."

Here are some things to consider when managing DNR patients:

Make efforts to determine the patient’s current wishes. "Maybe their grandchild is going to be born next week, but when the patient first filled out the paper they never foresaw that," Larkin says. "We have to allow for people to change their minds."

If a patient is clearly dying of pancreatic cancer and has already outlived their prognosis, then it’s unethical to try and resuscitate them against a valid DNR, Larkin says. "On the other hand, how valid is an old piece of paper with cobwebs crumpled up in the attic of the patient’s summer cottage in the Hamptons?" he asks.

Consider all types of evidence of the patient’s wishes. Some patients may dislike dealing with attorneys, and instead scribble on a piece of paper, "I never want to have CPR,’ or ‘please let me die comfortably’ "If a caretaker of that patient tells you that he wrote this yesterday because he knew he was dying, you can take that as prima facie evidence of the patient’s wishes," says Larkin. However, it may be another story if it’s a note from a healthy 16-year old. "Every case is different, and you have to look at each one individually," he stresses.

Take responsibility for your decisions. "If it’s a gray area, stand back from the decision and ask yourself, ‘Am I willing to take the heat for this?’" Larkin suggests. "Document to some degree your thinking process, showing you have considered the pros and cons. Sometimes it’s a matter of choosing the lesser of two evils. Covey aside, there is not always hope for a win-win situation. We must remember, ‘First, do no harm,’ and minimize the loss to the patients and their families."

Don’t let fear of being sued affect your treatment decisions. "Doctors can be sued for anything and they are, but that shouldn’t be the ultimate arbiter of what’s right or wrong," says Larkin. "The most important thing is to practice medicine in a way that honors patients and your profession."

Have protocols in place. "Protocols give you a framework for dealing with end-of-life issues, which makes it a lot less stressful on the personnel responding to the situation," says Dimitrakopoulos. "The place to make decisions isn’t at the bedside."

Although each case should be handled on an individual basis, protocols are helpful guidelines. "Some people have advanced directives or family members to state their wishes, and others don’t," says Dimitrakopoulos. "If it’s not a strictly medical decision, protocols make the playing field equal. So, if it’s something out of the ordinary, there’s something for everyone to refer back to."

Don’t hesitate to try to convince the patient. "I think that’s part of informed consent—you have an obligation to tell a patient all the possibilities, including that this treatment very likely could result in a positive outcome, and that you’re very hesitant to withhold treatment because it could end their life," says Dimitrakopolous.

Find out why a patient is refusing. It’s very important for the health care provider to make sure they know why the patient is refusing treatment, says Dimitrakopolous. "They may tell you, ‘I’ve been a chronic lung patient and I’ve been intubated before, and I don’t want to go through that hell again,’ but you need to know the patient understands the consequences or the chances for a positive outcome," she explains.

Make sure the patient is competent. "If you don’t think a patient is competent to make a decision, you do what is best for the patient," Larkin emphasizes. "Patient autonomy is important, and you can’t let that interfere with being a doctor. There may be time to decide later to decide what’s right or wrong, but you need to treat them at that time."