Do-not-resuscitate (DNR)

DNR Every patient is presumed to consent to the administration of CPR in the event of cardiac or respiratory arrest, unless a do-not- resuscitate (DNR) order is written. A DNR order is an order to refrain from using measures to restore or support cardiac or respiratory function in the event of a cardiac or respiratory arrest.

DNR cont… DNR orders are compatible with maximal therapeutic care. DNR orders never imply withdrawal of all medical and nursing care

Discussing DNR orders The issue of CPR should be addressed early in the treatment course of a patient, especially with those who have serious illnesses. The conversation should emphasize and discuss the therapeutic and comfort measures that providers will use. Many patients/ healthcare agents fear abandonment when a DNR order is written, so it is important for providers to attend to these concerns.

Discussing DNR orders cont… Questions about CPR need to be asked in the specific context of the patient’s problems. Providers should avoid questions such as: – “Do you want us to do everything?” AND – “Do you want us to start your heart if it stops?”— the latter implies that we can in fact restart the patient’s heart. DNR discussions should be a part of the overall care plan.

Who can make DNR decisions When the patient has decision-making capacity a DNR decision will be reached consensually by the patient and provider When the patient is incapacitated and has a health care agent, a DNR decision will be reached consensually between the health care agent and provider When the patient is incapacitated and has no health care agent, the provider can initiate the “Candidate for Non-Resuscitation” process

Candidate for Non-Resuscitation A candidate for non-resuscitation is a patient who meets the following criteria: – Lacks decision-making capacity – Has no authorized person who is reasonably available to make a decision with regard to a DNR order – Has been determined to a reasonable degree of medical certainty by the patient’s attending and one licensed physician, to meet any one of the following three criteria: Has a medical condition which can reasonably be expected to result in the imminent death of the patient; Is in a non-cognitive state with no reasonable possibility of regaining cognitive functions; Is a person for whom cardiopulmonary resuscitation would be medically futile in that such resuscitation would likely be unsuccessful in restoring cardiac and respiratory function OR will only restore cardiac and respiratory function for a brief period of time so that the patient will likely experience repeated need for cardiopulmonary resuscitation over a short period of time OR that such resuscitation would be otherwise medically futile

Candidate for Non-Resuscitation cont… When the criteria for candidacy for non- resuscitation are met, the ethics committee should be called to convene a DNR panel.

What a DNR order should include Documentation or co-signing of the order by the attending. Documentation in EPIC of: – The discussion the provider had with the patient and/or health care agent – Specific orders about what treatments are to continue – Change the code status designation in EPIC Orders should be reviewed at least every 7 days.

DNR during surgery or anesthesia DNR orders may be modified/suspended during the peri-operative period. – If an order is modified/suspended, the physician obtaining consent for the surgery must discuss and the have patient or health care agent agree to this change in orders. – All conversations and changes should be documented in the patients medical record. Upon arrival to the PACU, any modification/suspension will cease and original orders will stand.

DNR conflict or uncertainty In the event that: – the authority of the DNR order is in question or – the DNR order is unclear or – there is an ethical conflict or uncertainty about DNR orders The provider should contact the ethics committee and/or general counsel.