Do Not Resuscitate Orders : What They Mean ?

Do Not Resuscitate Orders : What They Mean ?

Dr Syed Raza

DNR Department of Natural Resources

DNR Digital Noise Reduction

DNR Do Not Remove

DNR Do Not Reply

DNR Dynamic Noise Reduction

DNR Domain Name Registration

DNR DotnetRocks (.NET software radio show)

DNR Deutsche Naturschutzring (German: German Nature Ring)

DNR Did Not Report

DNR Do Not Remember (adoption)

DNR Do Not Reduce

A Do Not Attempt Resuscitation (DNAR) order, also known as Do Not Resuscitate (DNR ) order is written by a licensed physician in consultation with a patient or surrogate decision maker.

Futility

A situation in which providing cardio-pulmonary resuscitation produces burdens (risks and complications) which far outweigh benefits .

It is not a death sentence

CPR started by Anesthesiologists in 1960s

DNR introduced by AHA in 1974 as it was recognized that many patients following CPR survived but with significant comorbidities.

The usual circumstances in which it is appropriate NOT to resuscitate are:

• when it will not restart the heart or breathing• when there is no benefit to the patient• when the benefits are outweighed by the

burdens

Common Scenario !

56 years old , Ex heavy smoker.Diabetic with Diabetic Nephropathy(CKD Stage5)Metastatic Lung cancer.Anterior wall MI one year ago , LVEF 20%Admitted with chest infection – No complications.Will you sign him for DNR ?

Another Scenario

78 years oldType 2 DM, HPNAdmitted with chest infection that resulted in septic shock.Renal and liver function tests somewhat impaired.

Will you sign him for DNR ?

When should CPR be administered?

In absence of a valid physician’s order to forgo CPR, if a patient experiences cardiac or respiratory arrest.

Role of patient Autonomy

Rights of adult patients and their surrogate decision maker to make medical decisions should be respected.

This concept is reinforced legally in the Patient Self Determination Act of 1991.

What if patients are unable to express their wishes ?

1.Advance Care Planning (Advance Directive) a. Living Will b. Power of Attorney

2. Surrogate Decision Maker

When should CPR be withheld?

Two general situations when CPR does not always provide direct medical benefit :

1. When CPR will likely be ineffective and has minimal potential to provide direct medical benefit to the patient.2. When the patient with intact decision making capacity or a surrogate decision maker explicitly requests to forgo CPR.

How is DNR order written?• Physicians should discuss the resuscitation

preferences with the patients /surrogate decision maker.

• Take into account Advance Directive if any.• Conversation should be documented in patient’s

notes.• Final decision should be explicit.• Indicate who were present during the conversation. • DNR Form is filled and signed by all parties

concerned

If CPR is deemed futile, should a DNR order be written despite patient

requests CPR.

Physician may over rule patient’s decision but still patient to be involved in the decision making conversation.

What if patient wants a DNR order despite CPR is not futile ?

Patient’s decision should be respected and honored.

This is respecting patient’s autonomy and is supported by law in most countries that

recognize a competent patient’s right to refuse treatment.

What if family disagrees with DNR order ?

Conversation with family members in order to clarify the benefits and risks of CPR and reasonable explanation in most situation will help to resolve the issue.

If not, this should be referred to the Ethics committee.

What are ‘slow codes ‘ or ‘show codes’?

Are forms of ‘symbolic resuscitation’. ‘Slow Code’ : Full effort of resuscitation is not applied.‘Show Code’ : A vigorous but short CPR is performed to please the family.

They undermine the rights of patients to be involved in clinical decisions, is deceptive and violates the trust the patients have in healthcare providers.

Why Bother?

Advance Directives

• Written instructions about future medical care (legal document)

• Only used: – If you are seriously ill or injured, and–Unable to speak for yourself

• Can be done in two ways:– Living will –Medical (health care) power of attorney

Why You Need Advance Directives• Your wishes will be known• Only used if you are unable to express your

decisions • This can happen to anyone – at any age • Give your loved ones the gift of peace of mind

– write down your wishes!

Interesting to note…

• Most Americans – 88 percent – feel comfortable discussing issues relating to death and dying*

• Yet only 42% have a living will*

*National Survey on Death, Dying, and Hospice Care in America, VITAS Innovative Healthcare, 2004

Factors Affecting Decision-Making and Communication

• Cultural, ethnic and age-related differences in approaches to decision-making.

• Capacity or ability to comprehend information, contemplate options, evaluate risks and consequences, and communicate decisions as determined by clinicians (articulate benefits and burdens).

• Competence or ability to make decisions as determined legally by a court of law.

Clear Decision : Medico-legal Issues

67 year-old Jill Baker found she had had a DNR order written on her medical notes without her consent. "She was understandably distressed by this as no discussion had taken place with her or her next of kin," said a doctor.

BBC News 27 June, 2000

Rule of Thumb

Rightness or wrongness of an action depends on the merits of the justification underlying the action, not the action itself.

Every situation needs to be evaluated in its own context, so that patients, families and caregivers can achieve comfort and trust in the final decisions.

Withholding/Withdrawing of Treatment

Easier to withhold than to withdraw treatment.Done in special circumstances where medical therapy is likely to fail, has not been effective (beneficial) or has potential to cause more harm.Withdrawal may be in step down fashion.Should be discussed with patient /relatives and medical team.

Case 1• Mr. H is a 24-year-old man from a skilled nursing

facility. • Quadriplegic following cervical spine injury.• Has normal cognitive function and no problems with

respiration.• Admitted with pneumonia. • The resident doctor suggests antibiotics, chest

physiotherapy, and hydration. • Resident doctor also suggests "he should be a DNR,

based on medical futility." Do you agree? Is his case medically futile, and if so, why?

Case 2

• Mrs. W is an 81-year-old woman with colon cancer with liver metastases admitted to the hospital for chemotherapy.

• Because of her poor prognosis, you approach her about a DNR order, but she requests to be "a full code." Can you write a DNR order anyway?

Case 2 contd:

• After a goal oriented conversation, Mrs. W continues to request to be fully resuscitated in the setting of cardiopulmonary arrest. However, several days later, despite a worsening clinical condition, Mrs. W still requests to be a "full code."

• Your resident doctor suggests that you sign her out as a "slow code." Should you do this?

Summary • DNR is an important clinical decision.• DNR order should ideally be made by a senior

clinician.• Decision should be made in consultation with

the patient /relatives after a clear agreement is reached (patient autonomy should be respected.)

• Should be well documented. Can be revised and reversed.

• It has medico-legal implications.