Documentation of Prognosis and DNR Orders

Essential Components for Documenting Prognosis Discussions

The American Society of Clinical Oncology recommends documenting the actual discussion of prognosis, not just the prognosis itself, as studies show prognosis documentation occurs in only 38% of cases, yet patients are 2.2 times more likely to have a DNR order when prognosis discussions are documented 2, 3
The American Society of Clinical Oncology suggests recording specific prognostic information shared with the patient, including timeframes and expected clinical course, while acknowledging that physician prognostic estimates are systematically overestimated 2, 3
The American Society of Clinical Oncology advises including the patient's understanding and response to the prognostic information, as patients and physicians often place different values on end-of-life issues 2, 3
Document the patient's personal values, goals of care, and preferences for interventions, as this is frequently missed even when DNR discussions occur 1

The American Heart Association recommends stating clearly whether the patient had capacity at the time of the DNR decision, including the date of DNR order implementation, and documenting who participated in the discussion 1
The American Heart Association suggests listing exact interventions to be withheld, such as chest compressions, endotracheal intubation, mechanical ventilation, defibrillation, and vasopressors, and avoiding vague language 1
The American Heart Association advises explicitly stating that DNR does not affect other treatments unless specifically noted, and listing permitted interventions, such as supplemental oxygen, IV fluids, pain management, antibiotics, and comfort measures 1

The American Stroke Association recommends postponing new DNR orders until at least the second full day of hospitalization for conditions like intracerebral hemorrhage where early prognostication is unreliable 4, 1
The American Stroke Association suggests recognizing that early DNR orders become self-fulfilling prophecies, and providing aggressive guideline-concordant therapy initially for all patients without pre-existing advance directives 4

The American Society of Anesthesiologists recommends documenting whether DNR orders will be suspended during procedures, and discussing and agreeing upon this with the patient prior to the procedure 1, 5
The American Heart Association advises ensuring DNR documentation is portable, using ideal forms such as written bedside orders, wallet cards, identification bracelets, or standardized forms 6, 7