What is the approach to managing a patient with a do not escalate (DNE) and do not resuscitate (DNR) consent?

Managing Patients with Do Not Escalate (DNE) and Do Not Resuscitate (DNR) Consent

Patients with DNE and DNR consent should receive appropriate medical care that respects their wishes while maintaining dignity, with clear documentation of specific interventions to be withheld and those still permitted, along with regular review of these orders as the patient's condition changes.

Understanding DNE and DNR Orders

• DNR orders are specific medical orders (not advance directives) that instruct healthcare providers not to attempt cardiopulmonary resuscitation if the patient's heart or breathing stops 1, 2
• DNE designations indicate that providers should withhold new or higher-intensity interventions ("escalations") but not withdraw ongoing interventions 3
• Both orders must be clearly documented in writing, with DNR orders that refuse life-sustaining treatment being witnessed and explicitly stating they apply even when life is at risk 1, 2

Essential Documentation Requirements

• Patient's capacity at the time of decision-making and date of implementation 2
• Specific interventions to be withheld (e.g., endotracheal intubation, mechanical ventilation, vasopressors) 2, 3
• Interventions still permitted (e.g., supplemental oxygen, intravenous fluids, pain management, antibiotics) 2
• Record of discussion with patient and/or surrogate decision-maker, including patient's values, goals, and preferences 2
• Signatures of patient (if capable), surrogate decision-maker (if patient lacks capacity), and witnesses 2
• Information about when the order should be reviewed and process for modification 2

Approach to Patient Care

Initial Discussion and Documentation

• Engage in early discussions with patients about their preferences for end-of-life care before critical situations arise 1
• Document the rationale for DNE/DNR orders and discussions with the patient, surrogate, and family 2
• Clarify that DNE/DNR orders do not affect other treatments unless specifically noted 2
• Create a clear record in hospital notes indicating that the patient has been informed of the likely consequences of these decisions 1

Ongoing Care Management

• Continue providing reasonable and proper care, including all appropriate treatments not specifically refused 1
• Maintain enhanced nursing and monitoring facilities beyond those of a general medical ward for patients with acute respiratory failure requiring non-invasive ventilation 1
• Regularly review DNE/DNR orders, particularly if the patient's condition changes 2
• Consider palliative interventions when appropriate, which may be provided alongside therapies intended to prolong life 1

Communication with Healthcare Team

• Ensure all team members understand the specific limitations of care and interventions still permitted 2
• Use formal mechanisms (where available) to designate a patient as DNE/DNR to ensure consistency across providers 3
• Clarify the meaning of "escalation" for each patient to avoid ambiguity 3

Special Considerations

Qualified Consent

• Respect patients who qualify their general consent by refusing specific aspects of treatment 1
• Document the precise nature of restrictions imposed by the patient and the explanation of risks provided 1
• If an individual provider feels unable to provide proper care consistent with the patient's wishes, they can refuse to treat provided no additional harm results and reasonable attempts are made to find an alternative provider 1

Palliative Care Integration

• Consider palliative sedation for refractory symptoms at the end of life, with appropriate discussion of aims, benefits, risks, and alternatives 1
• Ensure patients and families understand that medical treatments and nursing care will continue to maintain comfort regardless of DNE/DNR status 1
• For terminally ill patients in severe distress who are actively dying, prioritize comfort measures even in the absence of advance directives 1

Common Pitfalls to Avoid

• Lack of clarity in limitation of resuscitation orders can complicate care 2
• Assuming DNE/DNR orders imply withholding other appropriate treatments 2
• Failing to review orders before procedures or surgery 2
• Not discussing DNE/DNR status with family members (with patient permission) 1
• Inadequate documentation of specific interventions to be withheld or continued 2