Do Not Resuscitate Orders (DNR):The Continued Dilemma

Alan Sanders, PhDDirector, Ethics, CHE Trinity Health

August 6, 2014

Question 1

An 80 yo F with HTN, hypothyroidism with a DNR comes to the ED c/o dizziness, SOB, and rapidly deteriorating (unstable) condition. She is unable to talk to you. Cardiac monitoring reveals SVT. Should you:

A. Cardiovert her.

B. Do not perform any electrical shocks, even if this results in her death.

C. Not enough information.

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Question 2

A 68 yo F with asthma and metastatic breast cancer with a DNR comes in with an asthma exacerbation triggered by an accidental exposure to a cat. She has impending respiratory failure. Should you:

A. Intubate her.

B. Do not intubate her, even if this results in her death.

C. Not enough information.

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Question 3

A 75 yo M with severe COPD (FEV1 0.7) with a DNR comes in with a COPD exacerbation and has impending respiratory failure. Should you:

A. Intubate him.

B. Do not intubate him, even if this results in his death.

C. Note enough information.

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The Fundamental Issue?

o From New Jersey POLST form, but representative of most, if not all states regarding the meaning of DNR

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What Does DNR mean?

o Only applies to basic CPR o Does not apply to all ACLS protocolso Does not have a shared meaning across RHM’s

“code teams”, “rapid response teams”, etc.o Does not mean “Do-not-treat”o Does not address treating pre-arrest conditions

(e.g. temporary ventilation for a DNAR patient who can be successfully treated for respiratory insufficiency)

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Pre-arrest period

Pre-arrest period may include failing heart and/or ineffective breathing; and may lead to cardiac or respiratory arrest if management failsPre-arrest period scenarios include managing

dysrhythmias, ventilatory insufficiency, ineffective gas exchange, respiratory failure

Use of ACLS protocols is not limited to cardiac and respiratory arrest situations; they are also used in the management of pre-arrest conditions and adverse clinical events.

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DNR & Advance Care Planning

o DNR/AND is very limited in the context of comprehensive advance care planning, especially in the acute care setting

o DNR/AND discussion often used as a substitute for advance care planning

o In the acute care setting, DNR/AND can serve as a “ceiling” for patients/families pushing for overly aggressive treatment

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CHE Legacy

o Caseo Woman with a DNI only (not DNR)o What does the DNI mean? o A wish to not live long term on ventilation?o What about short term for respiratory

insufficiency?

o Computerized Practitioner Order Entry (CPOE)o Standardization forced the ethical issue to be

addressed

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CHE Legacy Changes

New choices will be:• Full Resuscitation• DNAR (No Resuscitation)• DNAR (and Other Limitations) • DNAR (Comfort Measures Only)

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CHE Legacy cont.

3. DNAR (and Other Limitations)• Do not resuscitate in the event of cardiac and

respiratory arrest and ‘Do Not Provide’ the following therapies in a pre-arrest situation(allow multiple selections)o Artificial Ventilationo Intubationo IV Vasoactive Agentso IV AntiArrhythmic Agentso Cardioversiono Defibrillationo Blood or Blood Products

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Trinity Legacy

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• Full Resuscitation• Provide all therapy to prevent cardiac or

respiratory arrest.• DNAR

• No CPR efforts if cardiac or respiratory occurs. Provide all other therapies to prevent cardiac or respiratory arrest.

• DNAR and Do Not Provide the Following Therapies• Next slide

• DNAR Comfort Measures Only

Trinity Legacy cont.

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Other Health Systems

o Level I – Full treatment, including CPRo Level II – Selected Limitations, no CPR and:

o No Endotracheal Intubationo No Mechanical Ventilationo No Pacemaker Insertiono No Dialysiso No Electrical Defibrillationo No Invasive Monitoringo No Blood Productso No Vasopressorso No Inotropic drugs

o Level III – Comfort measures only

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Continued Questions

o Goal of CPOEo Communication in a crisis?o More thorough advance care planning?o Affects which options appear, where, how, to whom

o Meaning of code statuso Differs across institutionso Some have pre-arrest code teams

o Continued struggle for healthcare professionalso Interpretation, application, “re-training”o Communication of complex orders

o Outside of acute care?o EMT’s and out-of-hospital DNR orders

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