DNR Turning Into Do Not Treat?

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Does anyone ever feel like they encounter providers who approach DNRs in a way that basically turns them into a 'do not treat' scenario? I've had this issue several times lately where patients who were DNR, but not comfort measures or hospice, were experiencing something and were symptomatic, and when I called for orders the response I got was "oh that patient is a DNR" with no orders received. For example, I had a woman who was a DNR who had a blood pressure of 60/40 the other night and the hospitalist did not want to treat it, stating that she was a DNR. Or another instance recently where a DNR patient who was due to be discharged to rehab the next day aspirated, was in acute respiratory distress, and needed to be intubated, but when I called I was met with the "DNR" response from the doc. It frustrates the heck out of me. I've always approached the concept of DNR as a 'we do everything up until the moment the heart stops' unless of course there is a 'do not intubate' or a comfort measures/hospice order.

I'm trying to brainstorm ways to approach this issue that will get nursing and medical providers on the same page. How do your hospitals do it? Do any of you feel like you have this same issue?

Specializes in Critical care.

Personally I tend to lean toward the do not treat side, having worked in critical care for almost thirty years I am disgusted at the number of times family, or physicians, ignore the patient's end of life wishes.

An example would be your aspiration patient, maybe the patient aspirated before? Maybe they were previously intubated? Maybe they decided that they never wanted to have a PEG, or be intubated again? In that case of course I wouldn't treat them for the aspiration, because they didn't want it. Then someone will come along with the bright idea of intubating the patient .... WHY?!?!?! They will just aspirate again when the tube is taken out, seems like no one has the ability to look a week into the future. The patient still has aspiration issues! Heavy sigh .... I have told my kids I will come back and haunt their asses if they ever do that to me.

Cheers

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Specializes in CVICU, MICU, Burn ICU.

Palliative care providers are so valuable in these types of cases.

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Any DNR can be rescinded by any patient at any time. In any case, O2 and Morphine would be the least you could do for this person.

I agree, which is why I was horrified. Had to call the staff to actually get anything ordered. The resident left without doing anything.

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Specializes in Psych, Addictions, SOL (Student of Life).
I agree, which is why I was horrified. Had to call the staff to actually get anything ordered. The resident left without doing anything.

But in the scenario described it does not appear that anyone (The patient or designated decision maker) changed the DNR. If sublingual morphine or Ativan were available and the patient was designated DNR/Comfort measures only I would most likely have followed the DNR orders, Intubation would be considered an extraordinary measure.

Hppy

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Specializes in Emergency Department.

Part of the whole problem surrounding "DNR" is your intent matters as well as what's legally considered "resuscitation" in your state/area/hospital. For me, someone that has a DNR order is someone that has chosen the following:

  • No CPR
  • No Intubation
  • No assisted ventilation (CPAP is OK)
  • No "cardiotonic" drugs
  • No Defibrillation

The above only technically occurs in the setting of cardiopulmonary arrest. Until that occurs (and outside intubation and ventilation assist), everything is potentially on the table. Where things get sticky/confusing with this are those times when you need to resuscitate the patient but the patient isn't dead (like you need to provide fluids, pressors, etc) and you want to prevent further decline.

Now what I prefer is the POLST because it is far more explicit as to what the patient wants and allows in the event that the patient cannot speak for themselves.

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Specializes in Critical Care.
Any DNR can be rescinded by any patient at any time. In any case, O2 and Morphine would be the least you could do for this person.

Only DNR orders initiated by the patient can be rescinded, a patient can't reverse a DNR order where the physician found no medical purpose to resuscitation (ie a medical futility DNR).

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Only DNR orders initiated by the patient can be rescinded, a patient can't reverse a DNR order where the physician found no medical purpose to resuscitation (ie a medical futility DNR).

I'm assuming that the concept of and laws relating to medical futility and medical DNR's would vary from state to state.

The last I read there is no agreement among physicians on what exactly constitutes medical futility.

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Specializes in Critical Care.
I'm assuming that the concept of and laws relating to medical futility and medical DNR's would vary from state to state.

The last I read there is no agreement among physicians on what exactly constitutes medical futility.

It doesn't vary by state and there's not much disagreement on when certain treatments would be futile, there do seem to be regional cultural variations in futile treatment at the end of life.

The basic premise of a medical futility DNR is not actually specific to resuscitation, it's the same premise we use for instance if a patient were to tell a cardiothoracic surgeon that they want open heart surgery when there would be no benefit to surgery for the patient, it's a basic expectation that the surgeon would decline to operate on a patient where there would be no benefit.

Resuscitation is a medical intervention just as open heart surgery is, and it's no more appropriate to offer open heart surgery to a patient who we know wouldn't benefit from it than it is to offer resuscitation to a patient we know wouldn't benefit from it.

Resuscitation is well researched and we have a large database on causes of arrest vs outcomes, there are a number of situations where the potential for resuscitation to be beneficial aren't just low, but where we know with certainty it will be of no benefit, this is the universally accepted definition of medical futility.

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It doesn't vary by state and there's not much disagreement on when certain treatments would be futile

I am not finding proof that the concept of medical futility and laws relating to medical futility don't vary by state. Can you provide a link?

I disagree that there is not disagreement among physicians on what constitutes futile treatment. I believe you and I discussed this once in the past, and I recall telling you I found over 200,000 pages at a single internet search on this topic.

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Specializes in Critical Care.

No states have laws that prevent Physicians from declining to prescribe non-beneficial treatments, and actually state laws and regulations generally prohibit physicians from prescribing interventions they know have no potential for benefit.

There are certainly medical futility gray areas, in terms of what criteria determines medical futility in those cases where it is not absolute. It's only in these debatable cases where there is a potential benefit to be weighed against the harm of such an intervention, where some states have laws that define how the decision making process must be carried out (Texas and California for instance require that these decisions go through an ethics committee). In my experience, these gray area declarations are fairly rare, more often patients are declared a medically futile DNR when there are no pros and cons to weigh due to absolutely no potential for benefit.

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But in the scenario described it does not appear that anyone (The patient or designated decision maker) changed the DNR. If sublingual morphine or Ativan were available and the patient was designated DNR/Comfort measures only I would most likely have followed the DNR orders, Intubation would be considered an extraordinary measure.

Hppy

I was not expecting him to be intubated. I was looking for something to calm him down and make him comfortable.

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Specializes in Haem/Onc.

For my paeds patients we have advanced care plans that state exactly what circumstances we can and can't intervene, and what interventions we allow. A lot of them will say you can bag the child, but you can't intubate, or they want treatment if it's something reversible, such as choking or a treatable chest infection.

Is that different to the way things are done over there?

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