Dealing with Partial DNR Orders

Abstract & Commentary

Synopsis: This article points out the disadvantages of partial DNR orders—for both clinicians and patients—and offers clear steps for mitigating the problem by developing a supplemental patient care plan for patients who are less than "full code."

Source: Berger JT. Arch Intern Med. 2003;163(19): 2270-2275.

In this article, berger describes the all-too- common problems associated with use of partial "do-not-resuscitate" (DNR) orders. Partial DNR orders vary from specific refusal of a particular intervention (eg, do not intubate) to, at some institutions, an ability to pick and choose treatment components as though from a restaurant menu. Berger reviews the lack of data supporting the medical efficacy of these treatment plans. He also discusses the ethical issues surrounding the use of these orders, including the unknown level of informed consent obtained in formulating the care plan, the frequent violation of the principle of nonmaleficence resulting from partial resuscitation, and the application of the partial resuscitation order to pre-arrest care.

Berger suggests that partial resuscitation orders should generally be avoided and recommends instead the development of a supplemental care plan for patients for whom DNR orders are being written. The elements of such a plan include:

  1. Identification of patients’ treatment goals;
  2. Identification of specific medical interventions declined by the patient or surrogate;
  3. Allowing for physician judgment and discretion in determining the use of specific treatments in particular clinical circumstances, within the context of patients’ care objectives;
  4. Linking the patients’ or surrogates’ requests for specific treatments to goals of care to avoid medically inappropriate combinations of medical interventions;
  5. Making sure the plan can be readily interpreted by any physician likely to be a first responder to a medical emergency.

Comment by James E. McFeely, MD

With this article Berger has certainly hit a nerve with those in the critical care community. As first responders who are frequently left dealing with the outcomes of partial DNR orders, we are often asked to perform a procedure (the partial code) for which we have no expectation of a successful outcome. Berger rightly points out the lack of data supporting even providing these types of choices to a patient or family and acknowledges the lack of informed consent that is implicit in some of these choices. What physician has the time to discuss with a patient all the ramifications of the potential combinations from the code menu? Certainly few if any patients would choose certain combinations of partial resuscitation if they knew the implied futility in the choice, yet we have all seen these combinations at times.

Often when a partial resuscitation order is written I have the feeling that the physician thought it was the "best I could get," while realizing that given the patient’s overall condition, something more comprehensive would be medically appropriate.

Certainly there are clinical situations where less than a full resuscitation is appropriate, such as an end stage COPD patient who does not wish to be intubated. I think Berger’s suggestion for developing a supplemental treatment plan is a good one; and when accurately reflecting a patient’s treatment preferences may significantly facilitate, as Berger puts it, the "fluidity of thinking and subtlety of response" we all would prefer to provide this plan.

Comment by David J. Pierson, MD

Orders directing that cardiopulmonary resuscitation (CPR) be withheld if a patient experiences cardiac arrest are appropriate when the patient (or his or her appropriate surrogate) makes the rational decision to forego it, realizing that death will likely result, or when CPR cannot benefit the patient (medical futility). CPR is a complex array of procedures, not just chest compressions and electrical defibrillation. Standards for its optimal performance are increasingly evidence-based, and undergo frequent revision. Like other invasive procedures in the ICU, CPR has major costs and complications. The whole package, promptly and skillfully applied, can save lives and enable some patients to return to health who would otherwise die.

To someone from another planet who was learning of these things for the first time, the concept that a patient (or those who loved him or her) would decide in advance to selectively withhold parts of the CPR procedure while implementing others might well appear absurd: such a strategy could not hope to achieve the full potential benefit of CPR, yet would subject the patient to the discomfort and other adverse aspects of the procedure. It would seem to this alien visitor that only someone who did not grasp the facts of the situation—what CPR involved and its potential to help the patient—could possibly agree to an order directing that only parts of the CPR procedure would be carried out.

As clinicians in the ICU know only too well, as outlandish as this scenario sounds, it plays out all too frequently. Reasons vary, but they usually include problems with communication between the patient’s caregivers and the family. The product of these communication gaps may be partial DNR orders as discussed in this article.

In their book, Managing Death in the Intensive Care Unit, Curtis and Rubenfeld provide practical guidance for helping physicians and other caregivers to avoid the frustration and patient disservice of partial DNR orders.1 In the institution in which Curtis and Rubenfeld (and I) work, a standardized, university system-wide ICU order form specifies each patient’s code status.2 The form identifies two possible options: full code and DNAR (do not attempt resuscitation). Although it is possible in this system for physicians and patient surrogates to construct a partial DNR "menu" type order as discussed by Berger, this is a relatively unusual occurrence, thanks to the standardized order form and the practical guidelines on its back side to assist caregivers in approaching this issue with patients and families.

How DNR orders are handled varies substantially in different practice settings. As McFeely says, the issues discussed in the article by Berger strike a nerve for many ICU clinicians. The principles outlined in Berger’s article, and the guidelines he offers for developing a supplemental care plan for patients with partial DNR orders, can go a long way toward reducing caregiver frustration and improving care for these patients.

References

1. Curtis JR, Rubenfeld GD. Managing Death in the Intensive Care Unit: The Transition from Cure to Comfort. New York, NY: Oxford University Press, 2001.
2. Harborview Medical Center-University of Washington Medical Center "Do Not Attempt Resuscitation (DNAR) Order." Form UH 0822 (copy available from the editor at djp@u.washington.edu)

James E. McFeeley, MD Pulmonary and Critical Care Medicine, Alta Bates Summit Medical Center, Berkeley, CA, is Associate Editor for Critical Care Alert.
David J. Pierson, MD Pulmonary and Critical Care Medicine Harborview Medical Center University of Washington, is Editor for Critical Care Alert.