Does a Do Not Resuscitate - Breathing (DNR-B) order allow for intubation and the use of pressors (vasopressors)?

Understanding DNR-B Orders: Intubation and Vasopressors

A DNR-B (Do Not Resuscitate - Breathing) order specifically limits interventions related to breathing during cardiopulmonary arrest, but does not automatically prohibit intubation or the use of vasopressors in non-arrest situations. 1

What DNR-B Means

DNR orders are specific medical instructions that apply solely in the event of a cardiac or pulmonary arrest. They should explicitly specify which interventions are to be withheld:

• DNR-B typically means no intubation or mechanical ventilation during a cardiopulmonary arrest
• It does not automatically restrict these interventions in other clinical situations
• DNR orders should include clear documentation of which specific interventions are permitted or withheld 2

Common Misconceptions

Many healthcare providers incorrectly assume that DNR orders limit other aspects of care:

• Studies show that patients with DNR status often receive fewer interventions than clinically indicated 3
• The American Heart Association/American Stroke Association explicitly warns that DNR orders should not limit other medical and surgical interventions unless specifically stated 1
• In a survey study, 58% of patients with DNR/DNI orders actually wanted intubation for potentially reversible conditions like angioedema 4

Proper Implementation of DNR-B Orders

A properly documented DNR-B order should:

1. Explicitly state which interventions are prohibited specifically during cardiopulmonary arrest
2. Clarify which interventions are permitted in non-arrest situations
3. Include documentation of discussions with patient/surrogate/family
4. Provide rationale for the order 2

Intubation and Vasopressors with DNR-B

Intubation

• Intubation is typically prohibited during cardiopulmonary arrest with a DNR-B order
• However, intubation may still be appropriate for respiratory failure not associated with cardiac arrest
• The decision should be based on the specific language in the DNR order and the clinical context 2, 4

Vasopressors

• DNR orders do not automatically preclude the use of vasopressors
• Unless specifically included in the DNR order, vasopressors can be administered for hemodynamic support 2
• The American Heart Association recommends that all appropriate care, including vasopressors, should be administered unless explicitly restricted 1

Best Practices

1. Clearly document the scope of the DNR-B order:

   • Specify which interventions are prohibited during arrest vs. non-arrest situations
   • Create a checklist of permitted/withheld interventions including chest compressions, defibrillation, intubation, mechanical ventilation, and vasopressors 2

2. Regular review and communication:

   • Review DNR orders regularly, especially when clinical status changes
   • Ensure all team members understand the specific limitations of the order

3. Avoid self-fulfilling prophecies:

   • The American Heart Association recommends postponing new DNR orders until at least the second full day of hospitalization to avoid premature limitations of care 1
   • Aggressive care should be provided initially to allow accurate prognostication 1

Conclusion

DNR-B orders specifically limit breathing interventions during cardiopulmonary arrest but do not automatically prohibit intubation or vasopressors in other clinical situations. Clear documentation and communication about the specific scope of DNR orders are essential to ensure patients receive appropriate care aligned with their wishes.