DNR and DNI Orders in the ICU

Introduction to DNR/DNI Orders

• The American Heart Association recommends that aggressive full care should be provided early after ICU admission, and new DNR orders should be postponed until at least the second full day of hospitalization for most critically ill patients, particularly those with conditions like intracerebral hemorrhage where early prognostication is unreliable 1, 2

When to Consider DNR/DNI Orders

• The American Heart Association suggests avoiding early DNR orders in the first 24-48 hours unless the patient has pre-existing advance directives, as early care limitations become self-fulfilling prophecies of poor outcome due to inaccurately pessimistic prognostication 1, 2
• Early DNR orders (within the first day) have been identified as independent predictors of mortality, likely because they proxy for overall lack of aggressiveness of care rather than just withholding CPR 1
• Current outcome prediction models fail to account for the influence of withdrawal of support and early DNR orders, creating bias in prognostication 1
• DNR/DNI orders are appropriate when the patient has advanced age or terminal condition with short life expectancy, based on patient/family preference and clinical judgment of experienced providers 3
• DNR/DNI orders are appropriate when CPR would not prevent impending death to a reasonable degree of medical certainty (e.g., multiorgan failure with progressive metastatic cancer) 4, 5
• DNR/DNI orders are appropriate when the intervention cannot accomplish the intended physiological goals (futile intervention) 4, 5
• DNR/DNI orders are appropriate when the patient has transitioned to comfort-focused end-of-life care 6

Clinical Decision-Making

• The decision-making process should involve seeking patient or family preferences regarding aggressive resuscitation measures for patients admitted to the hospital 3
• The decision-making process should involve clinical judgment of experienced providers regarding expectation of outcome 3

Critical Distinctions About DNR/DNI Status

• DNR or DNI status does not limit the use of other treatments and should not result in withdrawal of appropriate medical care: vasopressors can still be administered, oxygen support continues, electrolyte replacement is appropriate, supplemental oxygen, IV fluids, pain management, and antibiotics remain indicated 6, 7
• DNR/DNI status can be suspended when surgery or invasive procedures are planned, after discussion and agreement with the patient prior to the procedure 6, 7, 8

Documentation Requirements

• Essential components that must be documented include: clear statement of patient's capacity at time of decision-making, date of DNR/DNI order implementation, specific interventions to be withheld, interventions that remain permitted, record of discussion with patient and/or surrogate decision-maker, including patient's values, goals, and preferences 7, 2
• The documentation must be written - oral DNR orders are not acceptable 7

Monitoring Considerations

• Arrhythmia monitoring may be considered in DNR/DNI patients if findings would trigger interventions consistent with patient wishes (e.g., rate control if symptomatic), but monitoring is not recommended when data will not be acted upon and comfort-focused care is the goal 6

Common Pitfalls to Avoid

• Self-fulfilling prophecies: Early DNR orders lead to less aggressive care, which then results in the predicted poor outcome 1, 2
• Failure to review: DNR orders should be reviewed periodically as per local protocol, particularly if the patient's condition changes 7
• Inadequate prognostication discussion documentation: Document the actual discussion of prognosis, not just the prognosis itself, as this significantly affects DNR decision-making 2

DNR Orders and Patient Communication

Introduction to DNR Orders

• The American College of Critical Care Medicine recommends that DNR orders should be discussed with the patient if they have decisional capacity, or with the patient's family/surrogate decision-maker if the patient lacks capacity, as a fundamental ethical and legal requirement for valid DNR orders 9, 10, 11

Decision-Making Framework for DNR Orders

• If the patient has decisional capacity, the patient has the right to give or withhold consent for a DNR order and must be directly involved in the discussion, according to the American College of Critical Care Medicine 11, 12
• If the patient lacks capacity, family members or legally appointed surrogate decision-makers must be engaged as sources of information about patient preferences and values, and may legally act as surrogate decision-makers, as stated by the Intensive Care Medicine society 9, 10

Communication Requirements

• The American College of Critical Care Medicine suggests starting by eliciting the patient's/surrogate's understanding of the medical situation rather than delivering an "opening monologue" 12
• The "Ask-Tell-Ask" approach should be used: ask permission to discuss prognosis, convey prognostic information, then assess understanding, as recommended by the Critical Care Medicine society 11, 12
• Key prognostic domains, including risks of short and long-term mortality, ventilator dependence, functional impairment, and cognitive impairment, should be explained, according to the Critical Care Medicine society 12

Surrogate Decision-Making Principles

• The surrogate's role should be clarified: most ICU decisions are value-laden and require the surrogate's input to personalize care to the patient's values, goals, and preferences, as stated by the Critical Care Medicine society 11
• The ethical goal is to enact the patient's previously stated treatment preferences if applicable and contemporary, not the surrogate's own preferences, according to the Critical Care Medicine society 11
• The preferred level of involvement of surrogates should be assessed, as they differ in their ability and willingness to share decisions, as recommended by the Intensive Care Medicine society 9, 10

Common Pitfalls to Avoid

• Inadequate family understanding can be avoided by ensuring that families have good understanding of life-sustaining treatments, level and intensity of support provided, and the patient's resuscitation status, according to the Intensive Care Medicine society 9, 10
• Failure to assess coping strategies can be avoided by identifying coping strategies used by each patient and/or family member to provide optimal communication and personalized goals of care discussions, as recommended by the Intensive Care Medicine society 9, 10
• Assuming surrogates refuse to discuss prognosis can be avoided by educating them about why this information is critical; if refusal persists, identifying an alternate surrogate or seeking ethics consultation, according to the Critical Care Medicine society 11, 12

DNR Orders and Shared Decision-Making

Decision-Making Framework

• Even critically ill patients should be asked for their input whenever feasible, rather than assuming they are too confused or sedated to contribute, according to the American College of Critical Care Medicine 13
• The patient's values, goals, and preferences must be elicited directly from them when possible, as recommended by the American College of Critical Care Medicine 13

The Shared Decision-Making Process

• The American College of Critical Care Medicine and American Thoracic Society recommend a default approach involving three key stages: information exchange, deliberation, and reaching agreement, with a strong emphasis on shared decision-making between clinicians and patient/family 14, 15, 16
• Clinicians should share information about treatment options, risks, and benefits, while the patient/surrogate shares information about the patient's values, goals, and preferences, as suggested by the American College of Critical Care Medicine and American Thoracic Society 14, 15
• Most surrogates prefer to share the authority and burden of decision-making with clinicians rather than making decisions independently, according to the American College of Critical Care Medicine and American Thoracic Society 14, 15
• Both clinicians and patient/surrogate should engage in back-and-forth discussions about the pros and cons of various options, as recommended by the American College of Critical Care Medicine 17, 13
• Clinicians and patients/surrogates should agree on the decision to implement, with the clinician offering a recommendation based on both medical facts and the patient's values, as suggested by the American College of Critical Care Medicine and American Thoracic Society 14, 16, 17, 13

Documentation and Authorization

• There is no requirement for multiple physicians to authorize a DNR order, and the attending physician should facilitate these discussions, as stated by the American Journal of Respiratory and Critical Care Medicine 18
• The decision is based on shared decision-making between clinicians and patient/family, not a committee of doctors, as recommended by the American College of Critical Care Medicine and American Thoracic Society 14, 15