Medical Decision-Making and Care for Patients with Life-Limiting Conditions

Introduction to Do Not Resuscitate (DNR) Orders

• A DNR order is a medical directive that specifies which life-sustaining interventions are to be withheld in the event of a cardiopulmonary arrest, but does not automatically limit other medical and surgical interventions, as stated by the American Heart Association/American Stroke Association 1
• The American Heart Association/American Stroke Association warns that DNR orders should not limit other medical and surgical interventions unless specifically stated, to avoid premature limitations of care 1

Scope and Documentation of DNR Orders

• DNR orders should explicitly specify which interventions are to be withheld, including clear documentation of which specific interventions are permitted or withheld during cardiopulmonary arrest and non-arrest situations, as recommended by the American Heart Association 1
• A properly documented DNR order should include explicit instructions for specific emergency interventions, clear specification of which interventions are to be withheld, documentation of discussions with patient/surrogate/family, and rationale for the DNR order 2

• The scope of a DNR order should explicitly specify which interventions are to be withheld, such as:

  Intervention	Permitted/Withheld
  Chest compressions	Withheld
  Defibrillation	Withheld
  Intubation	Withheld (during cardiopulmonary arrest)
  Mechanical ventilation	Withheld (during cardiopulmonary arrest)
  Administration of vasopressors	Permitted (unless specifically included in the order)
  Use of blood products	Permitted (unless specifically included in the order)
  Administration of antibiotics	Permitted (unless specifically included in the order)

  2, 3

Clinical Decision-Making for Patients with DNR Orders

• Intubation is typically prohibited during cardiopulmonary arrest with a DNR order, but may still be appropriate for respiratory failure not associated with cardiac arrest, based on the specific language in the DNR order and the clinical context, as guided by the American Heart Association 1
• The decision to administer vasopressors should be based on the specific language in the DNR order and the clinical context, unless specifically included in the DNR order, as recommended by the American Heart Association 1
• Patients with life-limiting conditions, such as gastrointestinal cancer and hypoxemia, should receive full aggressive care, including all appropriate medical and surgical interventions aimed at treating both the underlying condition and associated complications, as recommended by the American Heart Association 4
• The decision to transfer to ICU should be based on severity of respiratory compromise, need for invasive monitoring, potential for respiratory failure requiring mechanical ventilation, and hemodynamic instability 4

Communication and Patient Care

• Physicians should initiate discussions about CPR with all patients admitted for medical and surgical care or with their surrogates, being frank with the patient about the probability of surviving in-hospital cardiac arrest, as recommended by the American Heart Association 2
• The American Heart Association suggests reassuring the patient and family that pain control and symptom management will continue even if resuscitation is withheld 2
• A life vest (wearable defibrillator) can be part of a patient's treatment plan even with a DNR order in place, because DNR orders can be tailored to specific interventions, according to the American College of Cardiology 5, 2