DNR: “Do Not Resuscitate” or “Death Not Reversible”?

Shared Decision Making and DNR Orders

Currently, the decision to withhold or provide CPR is shared between the patient and/or his or her proxy decision maker and the physician caring for the patient. The physician's role is to provide clinical expertise and, when appropriate, advice to help the patient make a decision consistent with his or her values and preferences. The decision to provide or withhold CPR depends upon the acceptability of death as a clinical outcome. Shared decision making is an ideal process for patients when legitimate choices exist. ⁵

Unfortunately, for some patients, the process of shared decision making is problematic for four reasons. First, establishing patient preferences for CPR implies that an inevitable death could be reversible, engendering false hope that may impede acceptance of death and the implementation of palliative care. Second, the consent process demonstrates that decisional authority rests with the patient or his or her proxy decision maker, irrespective of the clinical reality. Recommending that a DNR order is “medically appropriate” does little to ameliorate this perception as recommendations are optional. Third, seeking consent to withhold CPR focuses on what will not, rather than what will be done for a dying patient. This can give rise to the perception that medical teams are “giving up” on a patient. Presenting CPR as the “default” option for all patients may also leave the perception that CPR should be performed. ⁶ Finally should families and/or dying patients wish to have CPR performed, repeated efforts to convince them otherwise can challenge their relationship with care providers.

An Example of Failed Consent for DNR

One of us recently cared for a patient ^* who was bedridden, cachexic, and had failed second-line chemotherapy for a progressive malignancy. The patient was not capable to make treatment decisions, and family members were asked whether CPR should be provided in the event of a cardiac arrest. The answer, unexpectedly, was “yes.” Efforts to overturn this decision, by emphasizing the “very small chance” of success and the potential for CPR to cause further suffering, were unsuccessful. Family members became angry when their invited opinions were repeatedly challenged. Conflict persisted to the point that an incident report was filed by nursing staff.

Unilateral DNR Orders Are Not an Effective Solution

Avoiding such conflicts by unilaterally writing a “no code,” “DNR,” or “DNACPR” order without communicating the decision to a patient and his or her family is problematic. Without establishing the context of care, a unilateral DNR order can reduce or eliminate trust in the healthcare team and leave a patient and his or her family unprepared for an inevitable death, and may even suggest that medical staff do not think the patient is worth saving. As well, the legal and professional acceptability of unilateral or covert DNR orders in the face of dissent is controversial and ill advised. ⁷

“DNR: Death Not Reversible” as an Alternative

Resuscitation needs to be talked about, ⁸ but what should be said? For all patients, at some point, death will become inevitable and this reality can and should be recognized before CPR is discussed. ⁹ Establishing acceptance of death as an inevitable outcome requires compassion and tact.

Initial efforts by healthcare teams to create rapport and trust with their patient and their caregivers are essential, and the illness experience of both parties must be explored. Understanding their recent experiences, their hopes, and their fears can also create opportunities for empathetic care and engender trust. Framing some discussions with the possibility that in the near future CPR may no longer be effective may facilitate transition to palliative care. One approach could be to say, “at this point CPR and admission to an ICU could be helpful. If it becomes clear that these treatments would no longer be potentially helpful, we would need to talk again.”

An alternative to shared decision making is to communicate to patients and families that the illness has advanced to the point that death, when it occurs, would not be reversible by CPR.

Physicians may used the following phrases to communicate the inevitability of death, which are difficult to misinterpret: “I wish I could give you different news but it is clear that your family member is coming to the end of his or her life. He or she would not survive CPR,” or “CPR or admission to an intensive care unit would not prevent him or her from dying at this point.” In some cases, acceptance of this information will be obvious. In others, exploration will be required. “How do you feel about this? Is this consistent with what you understand about your loved one's illness? How can we help you come to terms with this reality?” (See Box 1).

Communicating determinations of noneffectiveness should be considered allowable, and we believe, appropriate, when an attending physician believes that no reasonable physician would recommend that CPR be provided given the clinical context of the patient. After physician have communicated that the limits of treatment to sustain life have, sadly, been reached, patients and their families will require emotional support be available to help patients and their emotional support to be available to help them accept such news. Physicians may struggle to convince family members that a technologically prolonged death is not a viable option, and family members may fail to recognize that such deaths are harmful. ¹⁰ We believe that it is appropriate and accurate under some circumstances that physicians should clearly state that death, when it occurs will be irreversible. Families and patients are free to demand that efforts to prolong the dying process be undertaken, through the use of CPR and admission to an ICU, but we believe physicians have no obligation to establish preferences for this manner of dying.

Navigating Persistent Requests for Treatment

Patients or families may challenge the assessment that CPR would be futile, or express a wish for “miracles” and want CPR performed for this reason. Obtaining a second medical opinion from an intensive care physician is one option, since ICU transfers are necessary if circulation is restored with CPR after a cardiopulmonary arrest. Having the patient remain “full code” until a second opinion is obtained may help demonstrate impartiality. An ethics consult may be pursued ¹⁰ especially if policies supporting limits of care exist. Fortunately, persistent demands for CPR are rare, and can be effectively managed with compassionate and supportive care, and ethics committee support, without compromising the integrity of medical staff. ¹⁰

Case Outcome

In the case described, the family members were provided with an explanation that the patient was in the final stages of advanced cancer and were informed that death, when it occurred, would not be reversible. This was readily accepted with the following response, “Oh! Well. No one told me that!” Preferences for other potentially effective treatments were established, and emotional support for the family was offered. The benefit of palliative measures to improve comfort and, potentially, survival was explained. The patient was admitted for a trial of medical care with ongoing symptom control.

Conclusions

Some hospitalized patients can be recognized as actively dying. These patients need end-of-life care, and do not benefit from having their preferences to receive CPR established. In Canada, the requirement for, and capability of, physicians to identify dying patients has been codified in order that they may legally provide medical assistance in dying. ¹¹ Recognition of and respect for the professional capacity of physicians to identify patients at or very near the end of life is consistent with allowing them to communicate the irreversibility of death despite attempts at life-sustaining therapies. This approach is also consistent with the preferences of many seriously ill patients to have an authentic and honestly caring doctor–patient relationship. ¹²

We believe that under appropriate clinical circumstances, and with efforts to provide a supportive relationship, telling patients and their families that death, when it occurs, will not be reversible is a more rational approach than traditional shared decision making for establishing a DNR status for a patient. We also believe that if family members do not challenge this assessment with a specific request for CPR, that a DNR or do not administer CPR order can then be written.

Key Messages

Contributors and Sources

As practicing general internists, this essay was inspired by the multitude of conversations and their accompanying challenges we have encountered with individuals and their families when determining their preferences for life-sustaining therapies during hospital admission. Our shared interest in maintaining a reflective practice led to the determination that the current approach to goals-of-care conversations in hospitalized patients is leading to care that is misaligned with their underlying values. We have consulted the medical literature, our colleagues, our hospital administrators, and our patients to arrive at the proposed solution herein. K.Q. is a fifth year resident in general internal medicine who is pursuing his PhD examining the quality of care for frail elderly individuals, particularly those with terminal noncancer illnesses as they near the end of life. S.W. is an experienced clinician who has written extensively on the subject of dying. Both authors conceived the idea, wrote, and edited the essay in its entirety.