Is a Do Not Resuscitate (DNR) order justified for a quadriplegic patient based solely on medical futility, low quality of life, or low success rate of Cardiopulmonary Resuscitation (CPR)?

DNR Decisions for Quadriplegic Patients: Ethical and Medical Considerations

DNR decisions should never be based solely on quadriplegia, low quality of life perceptions, or low CPR success rates, but rather should involve the patient's expressed wishes and a thorough evaluation of medical appropriateness in each individual case. 1

Principles of DNR Decision-Making

Patient Autonomy is Paramount

• DNR orders should reflect the patient's own wishes whenever possible
• When patients cannot express their wishes, decisions should follow a shared decision-making model between surrogates and physicians 1
• Advance care planning discussions should occur before medical crises when possible 1

Medical Futility vs. Quality of Life

• Medical futility refers to interventions that have no reasonable chance of achieving the intended physiological effect
• Quality of life judgments are subjective and should not be the sole basis for DNR decisions
• CPR success rates alone (<1%) should not automatically trigger DNR orders without considering patient preferences 1

Appropriate Basis for DNR Decisions

Medical Futility Considerations

• Medical futility may be an appropriate basis for DNR when:
  • There is clear evidence that resuscitation would be physiologically futile
  • The intervention would not achieve its intended clinical goal
  • The burden of the intervention far outweighs any potential benefit 1

Patient Preferences

• Patient's previously expressed wishes through:
  • Advance directives
  • Living wills
  • Discussions with healthcare providers or family members 1
• When preferences are unknown, surrogate decision-makers should attempt to determine what the patient would have wanted 1

Inappropriate Bases for DNR Decisions

Disability Status Alone

• Quadriplegia by itself is not a valid reason for DNR orders
• Assumptions about quality of life based on disability status can reflect bias rather than patient values 1

Covering Team Making Unilateral Decisions

• Major medical decisions like DNR should not be made by covering teams without:
  • Knowledge of the patient's wishes
  • Consultation with the primary team
  • Discussion with the patient or surrogate decision-makers 1

Best Practices for DNR Decision-Making

Timing of DNR Discussions

• In patients with severe conditions who do not have preexisting documented requests, aggressive care including postponement of new DNR orders until at least the second full day of hospitalization is reasonable to improve outcomes 1
• Early DNR orders (within the first day) have been associated with increased mortality and may lower the likelihood of favorable functional outcomes 1

Scope of DNR Orders

• DNR orders should apply narrowly to resuscitation efforts only
• A DNR order does not affect any treatments other than those which would require intubation or CPR 1
• DNR orders should not limit other medical and surgical interventions unless explicitly specified 2

Common Pitfalls to Avoid

Self-Fulfilling Prophecy

• Early DNR orders can lead to less aggressive care overall, creating a "self-fulfilling prophecy" of poor outcomes 1
• Studies show that DNR orders are independently associated with increased risk of mortality 1

Confusing DNR with Withdrawal of Care

• DNR orders are specific to cardiopulmonary arrest situations
• They do not preclude access to other appropriate treatments such as antibiotics, surgery, or palliative care 1
• Limiting other medical interventions requires separate, explicit orders 2

Making Assumptions About Patient Preferences

• Healthcare providers should not assume they know what patients would want based on their disability status
• Frank discussions about the probability of surviving in-hospital cardiac arrest are important, as most patients can understand this information and make their own decisions 1

In conclusion, DNR decisions for quadriplegic patients should be based on the patient's expressed wishes and medical appropriateness, not assumptions about quality of life or disability status. Covering teams should not make unilateral DNR decisions without proper consultation and discussion with the patient or appropriate surrogates.