Decision-making to place a DNR order on a patient's record should include which of the following considerations (check all that apply):

Select one or more:

a.

Four to six minutes after cardiac arrest, or loss of circulation, the brain suffers significant damage, with resulting cognitive deficits, and if it is not performed quickly enough, CPR may result only in the rescue of a severely brain-damaged individual.

b.

A decision for "full code" ("Attempt CPR") or "no code" (DNR/DNAR) should be weighed carefully against the patient's overall condition, health, prognosis, and goals of treatment.

c.

The success rate for in-hospital CPR attempts is very low, particularly for elderly patients, where success is defined as "surviving to discharge with baseline neurological function intact."

d.

Elderly patients subjected to CPR often suffer secondary injuries, including cracked ribs, broken sternum, and damage to internal organs.

e.

CPR promises very different results for different patients, dramatically helping some and burdening others.

Transcribed Image Text:Do-Not-Resuscitate (DNR) Orders Mrs. Marcus is a 72-year-old woman with multiple medical problems, who was ad- mitted from a nursing home after being found unresponsive and hypotensive. This is the second time in recent weeks that Mrs. Marcus has been admitted. She was hos- pitalized for 18 days with pneumonia and a massive stroke. During that hospitaliza- tion, a feeding tube was placed. She was discharged to the nursing home and now readmitted 17 days later with aspiration pneumonia. She was intubated in the ED and successfully extubated several days later. Mrs. Marcus's daughter, Deborah, is her health care proxy agent. A living will, ex- ecuted on the same date as the proxy appointment, stipulates that if Mrs. Marcus's "brain has ceased to function," she would not want a variety of potentially life- sustaining interventions, including respiratory support, artificial nutrition and hy- dration, and antibiotics. Although Mrs. Marcus responds only to deep pain and her physicians do not expect her condition to change, Deborah is in favor of continued aggressive treatment, which she hopes will result in her mother's improvement. The attending believes that, if Mrs. Marcus suffers a cardiopulmonary arrest, she could survive a resuscitation attempt but would almost certainly be left in a much worse condition. For that reason, the care team has recommended a do-not-resuscitate (DNR) order to spare Mrs. Marcus an intervention that would increase her suffering without providing benefit. Deborah refuses to consent to a DNR order because the wording of the living will does not clarify what is meant by the "brain has ceased to function," and she does not think that forgoing resuscitation reflects her mother's wishes. She says that the living will is clear that her mother would not want to linger in a coma. Because she is not yet in that condition, however, Deborah is unwilling to consent to a DNR or- der or consider less-than-aggressive cure-oriented treatment at this time.
Transcribed Image Text:Another type of prospective decision making is the do-not-resuscitate (DNR) order. A DNR order means that cardiopulmonary resuscitation (CPR), including mouth-to-mouth resuscitation, external cardiac massage, intubation, and stimu- lants, will not be attempted if the patient suffers a cardiopulmonary arrest. Con- sent to a DNR order can be given either by a capacitated patient or by someone au- thorized to consent on the incapacitated patient's behalf. The ethical dilemma is that CPR's ability to prevent death can greatly benefit some patients and greatly burden others. In a young or otherwise healthy person, if cardiopulmonary function can be restarted within approximately four minutes, avoiding irreversible damage to brain and other organs, CPR can give back a life. In an elderly, demented, terminally ill person, one who has multiple serious health problems or has suffered severe and permanent damage, CPR can deprive the in- dividual of a peaceful death. Unfortunately, reports of successful resuscitations and dramatic television and film depictions of heroic rescue have played into popular belief in CPR's life-saving certainty. In fact, the brutal procedure is rarely effective on frail, debilitated, or ter- minally ill patients and may simply impose suffering and prolong dying. The criti- cal distinction between attempting and successfully achieving resuscitation accounts for widespread efforts to change the term from DNR to the more accurate DNAR (do not attempt resuscitation). Because of its profound implications, consent to forgo CPR is explicit and limited, not inferred or automatically transferred from one set- ting to another. Thus, DNRs must be renewed periodically, a specific discussion is necessary to suspend a DNR order during the perioperative period, a new DNR order must be entered upon admission to another care facility, and a nonhospital or community DNR must be written if the patient is returning home or to another residential situation. Even experienced physicians know that advising patients or, more often, fami- lies that CPR is not recommended is among the most difficult discussions in the clinical setting. No matter how sensitively it is presented, suggesting that life-saving efforts not be undertaken is distressing and frightening, an index of just how hope- less the patient's condition has become. Unfortunately, a common misperception is that DNR means do not treat, signaling a collective resignation to impending death and a scaling back of all treatment. Indeed, patients and families are often resis- tant to considering a DNR order because of the fear that the patient will receive less attentive care. A crucial task is clarifying for patients, families, and clinical staff that DNR forgoes only one intervention-cardiopulmonary resuscitation-and does not alter the rest of the care plan or the team's commitment to the patient. These discussions require all the judgment, skill, and compassion that practitioners can muster, and ethics consultations are often requested to assist in the process. Rather than an isolated conversation, the DNR discussion should be part of the overall review of the patient's changing clinical condition. Just as other interven- tions are evaluated in terms of whether they promote the patient's well-being, re- suscitation should be subjected to a benefit-burden analysis. Patients, families, and staff should clearly understand that it is the physiologically futile or clinically in- appropriate attempt rather than successful resuscitation that will be withheld. Discussions with Deborah should balance the benefits and burdens of resuscitation to help her view a DNR order as a way to protect her mother from a painful and

Question

Decision-making to place a DNR order on a patient's record should include which of the following considerations (check all that apply):

Select one or more:

a.

Four to six minutes after cardiac arrest, or loss of circulation, the brain suffers significant damage, with resulting cognitive deficits, and if it is not performed quickly enough, CPR may result only in the rescue of a severely brain-damaged individual.

b.

A decision for "full code" ("Attempt CPR") or "no code" (DNR/DNAR) should be weighed carefully against the patient's overall condition, health, prognosis, and goals of treatment.

c.

The success rate for in-hospital CPR attempts is very low, particularly for elderly patients, where success is defined as "surviving to discharge with baseline neurological function intact."

d.

Elderly patients subjected to CPR often suffer secondary injuries, including cracked ribs, broken sternum, and damage to internal organs.

e.

CPR promises very different results for different patients, dramatically helping some and burdening others.

Do-Not-Resuscitate (DNR) Orders
Mrs. Marcus is a 72-year-old woman with multiple medical problems, who was ad-
mitted from a nursing home after being found unresponsive and hypotensive. This
is the second time in recent weeks that Mrs. Marcus has been admitted. She was hos-
pitalized for 18 days with pneumonia and a massive stroke. During that hospitaliza-
tion, a feeding tube was placed. She was discharged to the nursing home and now
readmitted 17 days later with aspiration pneumonia. She was intubated in the ED
and successfully extubated several days later.
Mrs. Marcus's daughter, Deborah, is her health care proxy agent. A living will, ex-
ecuted on the same date as the proxy appointment, stipulates that if Mrs. Marcus's
"brain has ceased to function," she would not want a variety of potentially life-
sustaining interventions, including respiratory support, artificial nutrition and hy-
dration, and antibiotics. Although Mrs. Marcus responds only to deep pain and her
physicians do not expect her condition to change, Deborah is in favor of continued
aggressive treatment, which she hopes will result in her mother's improvement. The
attending believes that, if Mrs. Marcus suffers a cardiopulmonary arrest, she could
survive a resuscitation attempt but would almost certainly be left in a much worse
condition. For that reason, the care team has recommended a do-not-resuscitate
(DNR) order to spare Mrs. Marcus an intervention that would increase her suffering
without providing benefit.
Deborah refuses to consent to a DNR order because the wording of the living will
does not clarify what is meant by the "brain has ceased to function," and she does
not think that forgoing resuscitation reflects her mother's wishes. She says that the
living will is clear that her mother would not want to linger in a coma. Because she
is not yet in that condition, however, Deborah is unwilling to consent to a DNR or-
der or consider less-than-aggressive cure-oriented treatment at this time.

Another type of prospective decision making is the do-not-resuscitate (DNR)
order. A DNR order means that cardiopulmonary resuscitation (CPR), including
mouth-to-mouth resuscitation, external cardiac massage, intubation, and stimu-
lants, will not be attempted if the patient suffers a cardiopulmonary arrest. Con-
sent to a DNR order can be given either by a capacitated patient or by someone au-
thorized to consent on the incapacitated patient's behalf.
The ethical dilemma is that CPR's ability to prevent death can greatly benefit
some patients and greatly burden others. In a young or otherwise healthy person,
if cardiopulmonary function can be restarted within approximately four minutes,
avoiding irreversible damage to brain and other organs, CPR can give back a life.
In an elderly, demented, terminally ill person, one who has multiple serious health
problems or has suffered severe and permanent damage, CPR can deprive the in-
dividual of a peaceful death.
Unfortunately, reports of successful resuscitations and dramatic television and
film depictions of heroic rescue have played into popular belief in CPR's life-saving
certainty. In fact, the brutal procedure is rarely effective on frail, debilitated, or ter-
minally ill patients and may simply impose suffering and prolong dying. The criti-
cal distinction between attempting and successfully achieving resuscitation accounts
for widespread efforts to change the term from DNR to the more accurate DNAR
(do not attempt resuscitation). Because of its profound implications, consent to forgo
CPR is explicit and limited, not inferred or automatically transferred from one set-
ting to another. Thus, DNRs must be renewed periodically, a specific discussion is
necessary to suspend a DNR order during the perioperative period, a new DNR
order must be entered upon admission to another care facility, and a nonhospital
or community DNR must be written if the patient is returning home or to another
residential situation.
Even experienced physicians know that advising patients or, more often, fami-
lies that CPR is not recommended is among the most difficult discussions in the
clinical setting. No matter how sensitively it is presented, suggesting that life-saving
efforts not be undertaken is distressing and frightening, an index of just how hope-
less the patient's condition has become. Unfortunately, a common misperception
is that DNR means do not treat, signaling a collective resignation to impending death
and a scaling back of all treatment. Indeed, patients and families are often resis-
tant to considering a DNR order because of the fear that the patient will receive
less attentive care. A crucial task is clarifying for patients, families, and clinical staff
that DNR forgoes only one intervention-cardiopulmonary resuscitation-and does
not alter the rest of the care plan or the team's commitment to the patient. These
discussions require all the judgment, skill, and compassion that practitioners can
muster, and ethics consultations are often requested to assist in the process.
Rather than an isolated conversation, the DNR discussion should be part of the
overall review of the patient's changing clinical condition. Just as other interven-
tions are evaluated in terms of whether they promote the patient's well-being, re-
suscitation should be subjected to a benefit-burden analysis. Patients, families, and
staff should clearly understand that it is the physiologically futile or clinically in-
appropriate attempt rather than successful resuscitation that will be withheld.
Discussions with Deborah should balance the benefits and burdens of resuscitation
to help her view a DNR order as a way to protect her mother from a painful and

Accepted Answer

A Do-not-resuscitate  order is placed by the treating physician in a patient’s medical record so as…