# 024 Discussing DNR Orders-Part 2, 2nd ed

FAST FACTS AND CONCEPTS #024 PDF


Author(s): Charles F von Gunten MD, PhD and David E Weissman MD

Introduction The basic steps in the DNR discussion for seriously ill hospitalized patients were described In Fast Fact # 23. If you have followed those steps, what do you do if the patient or family/surrogate continues to want CPR and you think it is not in the patient's best interest? The seemingly unreasonable request for CPR typically stems from one of several themes:

1. Inaccurate information about CPR. The general public has an inflated perception of CPR success. While most people believe that CPR works 60-85% of the time, in fact the actual survival to hospital discharge is more like 10-15% for all patients, and less than 5% for the elderly and those with serious illnesses. This is a time to review/clarify the indications, contraindications, potential outcomes and morbidity of CPR. Start the discussion by asking, “What do you know about CPR?”

2. Hopes, fears, and guilt. Be aware that guilt (I haven't lived nearby to care for my dying mother) and fear (I am afraid to make a decision that could lead to my wife's death) are common motivating emotions for a persistent CPR request. Some patients or families need to be given an explicit recommendation, or permission from the physician, to stop all efforts to prolong life, to be told that that death is coming and that they no longer have to continue "fighting". Whenever possible, try to identify the underlying emotions and offer empathic comments that open the door to further conversation. This decision seems very hard for you. I want to give you the best medical care possible; I know you still want CPR, can you tell me more about your decision?

Agreeing to a DNR order for many patients feels equivalent to them "choosing" to die. Acceptance of impending death occurs over a vastly different time course for different patients/families; for some, it never occurs. Some patients see CPR as a "last chance" for continued life. Probe with open-ended questions: What do you expect to happen? What do you think would be done differently, after the resuscitation, that wasn't being done before? Many patients describe hope for a new treatment. Use the opportunity to respond by describing that you are doing everything in your power to prolong their life before a cardiopulmonary arrest – you wouldn't be "saving something" to do after they had died. If patients are not ready for a DNR order, don't let it distract you from other important end-of-life care needs; emphasize the goals that you are trying to achieve; save a repeat discussion for a future time; good care, relationship building and time will help resolve most conflicts.

3. Distrust of the medical care system. Patients or families may give you a clue that there is a fundamental distrust of doctors or the medical system; this should be addressed openly. What you said makes me wonder if you may not have full trust in the doctors and nurses to do what is best for you? Can you tell me about your concerns?

4. Managing persistent requests for CPR. Decide if you believe that CPR represents a futile medical treatment—that is, CPR cannot be expected to either restore cardiopulmonary function or to achieve the expressed goals of the patient (see Fast Fact #136). Physicians are not legally or ethically obligated to participate in a futile medical treatment, and some facilities have a policy that a physician may enter a DNR order in the chart against patient wishes. Aside from writing a DNR order without patient or family agreement, other options at this time include:

  • Transfer care to another physician chosen by the patient/family.
  • Plan to perform CPR at the time of death – but don't end the discussion. Engage the patient about her or his wishes if she or he survive the resuscitation attempt. Tell the patient that you need guidance because it is very likely that if she or he survives CPR, they will be on life support in the ICU, and they may not be able to make decisions for themselves; ask them (or the family) to help you determine guidelines for deciding whether to continue life-support measures. If not already done, clarify if there is a legal surrogate decision-maker.

References

  1. Cantor MD, et al. Do-Not-Resuscitate orders and medical futility. Arch Int Med. 2003; 163:2689-2694.
  2. Layson RT, OcConnell T. Must consent always be obtained for a Do-Not-Resuscitate order? Arch Int Med. 1996; 156:2617-2620..
  3. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. NEJM.1996; 334(24):1578-82.
  4. Council on Ethical and Judicial Affairs. Medical futility in end-of-life care: Report of the Council on Ethical and Judicial Affairs of the AMA. JAMA. 1999; 281:937-941.

Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2005. Current version re-copy-edited March 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Von Gunten CF, Weissman DE. Discussing DNR Orders – Part 2, 2nd Edition. Fast Facts and Concepts. July 2005; 24. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_024.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

ACGME Competencies: Medical Knowledge, Patient Care, Professionalism

Keyword(s): Communication