What to do for a patient with bradycardia (heart rate 44) and dizziness who has a Do Not Resuscitate (DNR) order?

Management of Bradycardia with Dizziness in a Patient with DNR Status

A patient with bradycardia (HR 44) and dizziness who has a DNR order should receive all appropriate medical interventions to address the symptomatic bradycardia, as DNR status only applies to cardiopulmonary arrest and does not limit other treatments.

Understanding DNR Status in the Context of Bradycardia

DNR status is commonly misinterpreted in clinical practice. According to AHA guidelines:

• A DNR order by definition only means no resuscitative efforts should be performed in the event of cardiopulmonary arrest 1
• DNR status does not limit the use of other treatments such as vasopressors, oxygen support, or electrolyte replacement 1
• DNR orders are often incorrectly associated with an overall lack of aggressiveness of care 1

Diagnostic Approach for Bradycardia with Dizziness

1. Immediate assessment:

   • Evaluate hemodynamic stability (blood pressure, oxygen saturation)
   • Obtain 12-lead ECG to determine type of bradycardia
   • Check for signs of poor perfusion (altered mental status, hypotension)
   • Review medication list for potential bradycardia-inducing agents

2. Laboratory evaluation:

   • Electrolytes (particularly potassium)
   • Thyroid function tests
   • Drug levels if applicable (digoxin, beta-blockers)

Treatment Algorithm for Symptomatic Bradycardia in DNR Patients

Step 1: Assess Hemodynamic Stability

• If unstable (hypotension, altered mental status): Proceed to immediate intervention
• If stable but symptomatic: Proceed with medical management

Step 2: Immediate Interventions for Symptomatic Bradycardia

• Administer atropine 0.5 mg IV (may repeat to maximum of 3 mg)
• Consider temporary transcutaneous pacing if atropine ineffective and patient consents
• Initiate dopamine (2-10 μg/kg/min) or epinephrine (2-10 μg/min) infusion if atropine ineffective

Step 3: Identify and Treat Underlying Causes

• Discontinue or adjust medications that may cause bradycardia
• Correct electrolyte abnormalities
• Treat underlying conditions (e.g., hypothyroidism, increased intracranial pressure)

Step 4: Consider Level of Care Escalation

• Transfer to telemetry/progressive care unit with arrhythmia monitoring 1
• Cardiology consultation for potential temporary or permanent pacemaker evaluation if appropriate and consistent with patient's goals of care

Important Considerations

1. Monitoring decisions:

   • Arrhythmia monitoring is appropriate if findings would trigger interventions consistent with patient wishes (e.g., rate control for symptomatic bradycardia) 1
   • Monitoring should guide therapy congruent with the patient's overall care wishes 1

2. Communication with patient:

   • Discuss goals of care and treatment options
   • Clarify that DNR status does not preclude treatment of reversible conditions
   • Document patient preferences regarding escalation of care

3. Common pitfalls to avoid:

   • Do not equate DNR with "comfort care measures only" 2
   • Do not withhold appropriate treatments solely based on DNR status 1
   • Remember that physicians and nurses caring for patients with DNR status should be reminded that the designation relates only to cardiopulmonary arrest 1

By following this approach, you can provide appropriate care for the patient's symptomatic bradycardia while respecting their DNR status and preferences regarding end-of-life care.