What to do for a patient with bradycardia (heart rate 15 beats per minute) who is Do Not Resuscate (DNR)?

From the Guidelines

For a patient with bradycardia with a heart rate of 15 beats per minute who has a Do Not Resuscitate (DNR) order, the primary approach should be to clarify the scope of the DNR and assess the patient's symptoms, then provide supportive care within those boundaries, which may include administering atropine if permitted by the DNR parameters, as guided by the American Heart Association guidelines 1. The management of such a patient requires careful consideration of the DNR order, which does not equate to "do not treat" but rather outlines specific limitations on resuscitative measures. Given the life-threatening nature of a heart rate of 15 beats per minute due to its impact on cardiac output and organ perfusion, it is crucial to understand what interventions are acceptable under the DNR order. Key considerations include:

• Assessing the patient's symptoms, such as dizziness, altered mental status, hypotension, or chest pain, to determine the need for intervention.
• Providing supportive care that aligns with the DNR order, which may encompass positioning the patient to optimize blood flow, administering oxygen if necessary, and ensuring IV access for potential medication administration.
• Considering the use of atropine, with a recommended dose of 0.5 mg IV every 3 to 5 minutes up to a maximum total dose of 3 mg, if this intervention is permitted under the DNR order and the patient is symptomatic, as per the guidelines 1.
• Evaluating the appropriateness of transcutaneous pacing if the DNR allows for such interventions and the patient exhibits severe symptoms. Throughout the management process, maintaining open communication with the patient, family members, and the healthcare team regarding the goals of care and the implications of the DNR order is essential. The focus should be on providing care that respects the patient's wishes as outlined in the DNR order while addressing the immediate health needs related to the bradycardia.

From the FDA Drug Label

Atropine Sulfate Injection, USP in clinical doses counteracts the peripheral dilatation and abrupt decrease in blood pressure produced by choline esters Adequate doses of atropine abolish various types of reflex vagal cardiac slowing or asystole The drug also prevents or abolishes bradycardia or asystole produced by injection of choline esters, anticholinesterase agents or other parasympathomimetic drugs, and cardiac arrest produced by stimulation of the vagus.

For a patient with bradycardia (heart rate 15 beats per minute) who is Do Not Resuscitate (DNR), the use of atropine may be considered to counteract the bradycardia. However, given the patient's DNR status, the primary goal is to provide comfort and not to aggressively treat the bradycardia.

• The patient's DNR status takes precedence over treatment of the bradycardia.
• Atropine may be used to treat the bradycardia, but the patient's DNR status should be respected and no further resuscitative efforts should be made 2.

From the Research

Management of Bradycardia

• The patient's heart rate is 15 beats per minute, which is considered bradycardia 3, 4, 5.
• For symptomatic patients, treatment with atropine is recommended in the acute setting 3, 4.
• However, there is a case report of a patient with bradycardia who experienced paradoxical worsening of bradycardia following atropine administration 6.
• The patient is Do Not Resuscitate (DNR), which should be taken into consideration when determining the management plan.

Considerations for DNR Patients

• The DNR status indicates that the patient does not want to receive cardiopulmonary resuscitation if their heart stops or if they stop breathing 3, 4.
• The management plan should focus on providing comfort and alleviating symptoms, rather than attempting to reverse the bradycardia 7, 5.
• The patient's symptoms and underlying causes of the bradycardia should be evaluated to determine the best course of action 4, 5.

Treatment Options

• Atropine may not be the best option for this patient due to the risk of paradoxical worsening of bradycardia 6.
• Other treatment options, such as pacing or pharmacologic therapy, may be considered, but should be carefully evaluated in the context of the patient's DNR status and underlying medical condition 3, 4, 7, 5.