Managing Patients with DNAR Orders Who Need Bronchoscopy
When a patient with a Do Not Attempt Resuscitation (DNAR) order requires bronchoscopy but refuses to rescind it, the provider should proceed with the procedure while maintaining the DNAR status, implementing enhanced monitoring and safety measures to minimize risks.
Understanding the Situation
Bronchoscopy in patients with DNAR orders creates a challenging ethical and clinical scenario. The procedure carries inherent risks of complications that might require resuscitative measures, yet the patient's autonomy regarding end-of-life decisions must be respected.
Risk Assessment and Procedural Planning
Pre-procedure Considerations
- Thoroughly evaluate the urgency and necessity of the bronchoscopy 1
- Classify the procedure as emergent, urgent, or non-urgent 1
- Consider alternative diagnostic approaches if the bronchoscopy is non-urgent
- Ensure the patient fully understands the risks of maintaining DNAR during a procedure with potential complications
Risk Stratification
- Patients with DNAR orders should be considered high-risk for bronchoscopy 1
- Assess for specific risk factors:
- Respiratory status and oxygen requirements
- Cardiovascular stability
- Underlying comorbidities
- Current medication regimen
Procedural Protocol for DNAR Patients
Enhanced Monitoring Requirements
- Implement continuous multi-modal physiological monitoring throughout the procedure 1
- Ensure continuous pulse oximetry, ECG monitoring, and blood pressure monitoring 2
- Have resuscitation equipment readily available, even with DNAR status 2
Sedation Considerations
- Use minimal sedation to maintain airway protective reflexes 3
- Titrate sedatives slowly with careful monitoring 3
- Consider using midazolam at reduced doses, administered over at least 2 minutes with 2+ minutes between doses to evaluate effect 3
- Be aware that midazolam can depress respiration, especially in high-risk patients 3
Procedural Safeguards
- Use the smallest appropriate bronchoscope to minimize airway obstruction 2
- Ensure adequate oxygenation throughout the procedure 1
- If intubated, use a swivel connector with perforated diaphragm to maintain ventilation 1
- Adjust ventilator settings to mandatory mode with increased pressure limits if applicable 1
- Pre-oxygenate with 100% oxygen 1
Post-procedure Care
- Continue monitoring for at least 60-90 minutes after the procedure 1
- Provide supplemental oxygen as needed 1
- Monitor for return of gag reflex before allowing oral intake 1
- Provide clear written instructions about potential complications 2
Documentation and Communication
- Document the discussion regarding DNAR status during bronchoscopy
- Clearly communicate the DNAR status to all team members involved in the procedure
- Document the specific limitations of interventions in case of complications
- Ensure the DNAR order is prominently displayed in the procedure area
Common Pitfalls and How to Avoid Them
Automatic rescinding of DNAR orders for procedures
- This violates patient autonomy and is not recommended
- Instead, have a detailed discussion about specific interventions that may be needed
Inadequate sedation due to fear of complications
- Under-sedation can lead to patient distress and procedural difficulties 4
- Use appropriate monitoring to allow safe sedation tailored to the patient's condition
Assuming DNAR means "do not treat"
- DNAR specifically refers to cardiopulmonary resuscitation
- Other interventions for complications (oxygen, positioning, medications) may still be appropriate
Poor communication about DNAR limitations
- Ensure all team members understand exactly which interventions are permitted
- Specify which complications will be treated and how
By following these guidelines, providers can respect the patient's DNAR wishes while safely performing necessary bronchoscopic procedures with appropriate risk mitigation strategies.