What is the primary recommendation for a patient with a Do Not Resuscitate (DNR) order due to end-stage metastases?

Management of Patients with DNR Orders Due to End-Stage Metastases

For patients with DNR orders due to end-stage metastases, early introduction of expert palliative care, including effective control of pain and other symptoms, should be the primary recommendation and priority.1

Palliative Care Approach

Immediate Priorities

• Focus on symptom management rather than disease-modifying treatments
• Ensure adequate pain control with appropriate opioid titration 1
• Address dyspnea with opioids (first-line treatment) 1
• Manage other distressing symptoms (nausea, constipation, delirium)
• Provide psychological and spiritual support

Understanding DNR Orders

• DNR orders specifically limit resuscitative efforts but do not imply withholding other appropriate treatments 2
• DNR orders should explicitly specify which interventions are to be withheld:
  • Chest compressions
  • Defibrillation
  • Intubation
  • Mechanical ventilation
  • Administration of vasopressors
  • Use of blood products

Advance Care Planning

• Confirm and ensure complete documentation of advance care directives 1
• Determine patient and family preferences for location of death 1
• Discuss goals of care and ensure alignment between patient, family, and healthcare team

Evidence-Based Interventions

Symptom Management

1. Pain control

   • Opioids can be titrated aggressively for moderate/severe pain 1
   • Do not reduce opioid doses solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for symptom management 1

2. Dyspnea management

   • Opioids are first-line treatment 1
   • Benzodiazepines for associated anxiety 1
   • Steroids for specific causes (lymphangitis carcinomatosis, radiation-induced pneumonitis) 1
   • Oxygen therapy only if hypoxic 1

3. Delirium management

   • Remove unnecessary medications and medical devices 1
   • Consider haloperidol, risperidone, olanzapine, or quetiapine 1
   • Lorazepam for refractory agitation 1

Timing Considerations

• Early DNR discussions (more than 3 days before death) are associated with less aggressive procedures and more comfort measures 3
• Late DNR orders (within 3 days of death) are associated with higher in-hospital mortality, longer hospital stays, and longer ICU stays 4

Special Considerations

Surgical Patients

• DNR status should be clarified before any procedures
• Palliative surgical interventions may still be appropriate if they improve quality of life 5
• Formal palliative care consultation improves symptom management and end-of-life care 6

Brain Metastases

• Focus on symptom control (headaches, seizures, cognitive impairment)
• Consider steroid therapy for cerebral edema
• Comfort is the ultimate goal in providing good quality of life 7

Communication

• Discuss prognosis and advance care planning within 1 month of diagnosis of advanced cancer 1
• Ensure advance directives are available to all caregivers regardless of treatment setting 1
• Consider ethics, social work, or chaplaincy consultation to assist in conflict resolution when patient, family, and/or professional team disagree on interventions 1

Pitfalls to Avoid

1. Assuming DNR means "do not treat" - continue all appropriate non-resuscitative care
2. Failing to document specific limitations of care
3. Delaying palliative care consultation
4. Not addressing psychological and spiritual needs
5. Inadequate symptom management due to fear of hastening death
6. Poor communication about goals of care with patient and family

Remember that patients with DNR orders due to end-stage metastases should receive comprehensive palliative care focused on quality of life, with early introduction of expert palliative care services being the highest priority.