do not resuscitate (DNR); do not attempt rescuscitation (DNAR)
Introduction
A provision of autonomy.
There is NO direct relationship between an advance directives & a DNR order.
On nearly all advance directives forms, aspecific 'Do not resuscitate' needs to be explicitly stated.
DNR does not mean 'Do not treat'.
Many forms of life-prolonging treatments (including care in an intensive care unit) may be appropriate for a patient with a DNR order
Informed consent for a DNR order is similar to other procedures except that for a DNR order, the patient must consent NOT to receive treatment.
In some institutions, if a physician judges that resuscitation cannot achieve the goals of medicine ('futility'), the a 'rescuscitation not indicated' order may be written without a patient's consent; however,most physicians feel that the patient or surrogate should be given notice of such an order.
Some physicians feel that a DNR order should never be written without a patient's or surrogate's consent.
DNR orders in the operating room: Consensus is building that resuscitation preferences should be discussed prior to surgery, & increasingly institutions are permitting DNR orders to be carried into the OR setting.
A 'Do not resuscitate' note should include the following.
The patient is to have the 'Do not resuscitate' (DNR) code status. I have discussed the patient's wishes with the patient/(family member, durable power of attorney). The patient wishes/would wish to have the DNR code status. Specifically the patientdoes/would not want cardiopulmonary resuscitation including defibrillation, endotracheal intubation or advanced cardiac life support (ACLS) medications. All other medications and treatment will be provided including, but not limited to IV fluids & antibiotics. This service concurs with the patient's wishes & the patient is to have the DNR code status.
Notes
- often misused after cardiac arrest[4]
- frail patients are unlikely to survive to hospital discharge following in-hospital cardiac arrest[8]
- a frailty score can help formulate discussions[8]
- a 6-minute mock-code video increases election of DNR code status in hospitalized patients[5]
- ethics consult advises physicians to honor DNR tattoo on chest of 70 year old unconscious man with history of COPD, diabetes mellitus, & atrial fibrillation[6]
- CPR for a patient with a severe, highly contagious disease places an unacceptably high risk for health care professionals, especially if likelihood of survival is low (example ventilated COVID-19 patients)[7]
* Discussion of code status with critically-ill patients[9]
- open the conversation
- assess patient's perspective (understanding of illness, concerns, goals)
- share information
- align (empathic statement, then 'what are your thoughts?'
- make recommendation
- respond to patient's decsion
- document conversation
More general terms
Additional terms
References
- ↑ Rosenfeld K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ Rosenfeld K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 25-28, 2002
- ↑ Burns JP, Edwards J, Johnson J, Cassem NH, Truog RD. Do-not-resuscitate order after 25 years. Crit Care Med. 2003 May;31(5):1543-50. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12771631
- ↑ 4.0 4.1 Fendler TJ et al. Alignment of do-not-resuscitate status with patients' likelihood of favorable neurological survival after in-hospital cardiac arrest. JAMA 2015 Sep 22/29; 314:1264. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26393849
Angus DC et al. Successful resuscitation from in-hospital cardiac arrest - what happens next? JAMA 2015 Sep 22/29; 314:1238. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26393845 - ↑ 5.0 5.1 Merino AM et al. A randomized controlled trial of a CPR decision support video for patients admitted to the general medicine service. J Hosp Med 2017 Sep; 12:700. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28914272 <Internet> http://www.journalofhospitalmedicine.com/jhospmed/article/145134/hospital-medicine/randomized-controlled-trial-cpr-decision-support-video
- ↑ 6.0 6.1 Holt GE, Sarmento B, Kett D, Goodman KW. An Unconscious Patient with a DNR Tattoo N Engl J Med 2017; 377:2192-2193. Nov 30, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29171810 Free Article <Internet> http://www.nejm.org/doi/full/10.1056/NEJMc1713344
- ↑ 7.0 7.1 American Medical Association. April 29, 2020 DNR orders in a public health crisis https://www.ama-assn.org/delivering-care/ethics/dnr-orders-public-health-crisis
- ↑ 8.0 8.1 8.2 Ibitoye SE, Rawlinson S, Cavanagh A et al Frailty status predicts futility of cardiopulmonary resuscitation in older adults. Age and Ageing. June 5, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32500916 https://academic.oup.com/ageing/advance-article-abstract/doi/10.1093/ageing/afaa104/5851510?redirectedFrom=fulltext
- ↑ 9.0 9.1 Jacobsen JC et al Case 19-2020: A 74-Year-Old Man with Acute Respiratory Failure and Unclear Goals of Care. N Engl J Med 2020; 382:2450-2457 June 18, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32459917 https://www.nejm.org/doi/full/10.1056/NEJMcpc2002419