What is the discussion about Do Not Resuscitate (DNR) orders and comfort measures?

From the Guidelines

DNR orders and comfort measures are crucial end-of-life care decisions that prioritize a patient's comfort and dignity over life-prolonging interventions, and should be discussed early with healthcare providers through advance care planning conversations. A DNR order instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's heart stops or they stop breathing. Comfort measures, also called palliative care, focus on relieving symptoms and improving quality of life rather than curing the underlying condition. These typically include medications for pain management (such as morphine 2-4mg IV every 2-4 hours as needed), anti-anxiety medications (like lorazepam 0.5-1mg every 4-6 hours), and treatments for respiratory distress (such as low-dose morphine or hydromorphone) 1.

Key Considerations

• DNR orders should be completed, signed, and dated by the physician after a documented discussion with the patient and/or family or legal representative 1.
• Comfort measures only is a different approach to caring at the end of life, and should be considered when all potential treatments have either failed or been rejected by the patient and/or family as excessively burdensome 1.
• Palliative sedation at the end of life, when nothing else has worked, with the goal of comfort during the dying process, can be employed using the doctrine of double effect, which morally justifies an act that has two possible effects, one that is desired (good) and one that is not desired (bad) 1.

Implementation

• Advance directives, living wills, and durable power of attorney for health care and patient self-determination should be discussed with and documented for all patients admitted to the hospital 1.
• The goal of DNR orders and comfort measures is to ensure dignity and comfort while respecting the patient's wishes about avoiding invasive interventions that may cause suffering without meaningful benefit.
• These approaches recognize that at certain stages of illness, focusing on comfort rather than cure can provide the most compassionate care 1.

From the Research

Discussion on Do Not Resuscitate (DNR) Orders and Comfort Measures

The discussion around DNR orders and comfort measures is multifaceted, involving ethical, legal, and economic considerations 2. Key aspects of this discussion include:

• The prevalence of DNR orders, which has been found to be increasing over time, with 68% of patients who died having a DNR order written, including 94% with malignancy and half of patients with cardiovascular disease 2.
• The timing of DNR orders, with most orders (61%) being written within three days of death, and 64% written on medical-surgical floors and 34% in critical care units 2.
• The involvement of patients and families in DNR decision-making, with documentation showing only 14% of patients but 77% of families being consulted 2.
• The impact of DNR orders on clinical care, with a significant reduction in vital signs documentation, tests completed, documentation, and visits by physicians after DNR orders, but no change in nursing care and comfort measures 3.

Patient Perspectives on DNR Orders

Patients' perspectives on DNR orders vary, with some requesting DNR orders based on personal, relational, or philosophical considerations, and others preferring full code orders 4. Key findings include:

• DNR patients reported greater familiarity with the subject and described a more positive experience with resuscitation discussions than full code patients 4.
• DNR patients understood resuscitation in graphic, concrete terms, emphasizing suffering and futility, while full code patients understood resuscitation in an abstract sense as something that restores life 4.
• Patients' preferences for resuscitation were influenced by their personal values, relationships, and philosophical beliefs 4.

Improving DNR Ordering Processes

Efforts to improve DNR ordering processes have focused on reducing errors and miscommunication between healthcare providers 5. Key strategies include:

• Implementing electronic ordering systems with automated printing of resuscitation status armbands 5.
• Designing and integrating new DNR armbands to improve communication accuracy 5.
• Evaluating the impact of changes on communication accuracy and patient outcomes 5.
• Using registry data to examine treatment order combinations and identify areas for improvement 6.

Treatment Order Combinations

Analysis of treatment order combinations has revealed varying patterns of DNR and comfort measures orders 6. Key findings include:

• The most common order combinations were DNR/Comfort Measures Only, DNR/Limited Interventions, and Attempt Resuscitation/Full Treatment 6.
• Other order combinations, such as Attempt CPR/Comfort Measures Only, required interpretation at the time of a crisis and were completed for about 10% of registrants 6.