Do Not Resuscitate Orders : What They Mean ?

Most doctors working in Acute areas know when and how to do CPR. However, most get stuck when it comes to ' When not to do CPR' due to cultural, social, ethical and legal issues attached.

1. Do Not Resuscitate Orders :
What They Mean ?
Dr Syed Raza

3. 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

4. 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.

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

8. It is not a death sentence

10. 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.

11. 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

16. 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 ?

17. Another Scenario
78 years old
Type 2 DM, HPN
Admitted with chest infection that resulted in
septic shock.
Renal and liver function tests somewhat impaired.
Will you sign him for DNR ?

18. When should CPR be administered?
In absence of a valid physician’s order to forgo
CPR, if a patient experiences cardiac or
respiratory arrest.

19. 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.

20. 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

21. 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.

22. 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

23. 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.

24. 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.

25. 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.

26. 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.

27. Why Bother?

28. 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

29. 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!

30. 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

31. 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.

32. Clear Decision : Medico-legal Issues

33. 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

34. 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.

35. 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.

36. 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?

37. 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?

38. 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?

39. 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.