What is the recommended approach for a Do Not Escalate (DNE) and Do Not Resuscitate (DNR) consent model or format?

Recommended Approach for Do Not Escalate (DNE) and Do Not Resuscitate (DNR) Consent Model

The most effective DNE/DNR consent model should include clear documentation of the patient's capacity, specific interventions to be withheld or permitted, signatures of all relevant parties, and regular review provisions. 1, 2

Essential Components of DNR/DNE Consent Forms

Patient Information and Capacity

• The consent form must document the patient's capacity at the time of decision-making and the date of implementation 1
• A clear statement of who made the decision (patient or surrogate) should be included 1

Specific Interventions

• Forms should explicitly list which interventions are to be withheld, such as:
  • Cardiopulmonary resuscitation
  • Endotracheal intubation
  • Mechanical ventilation
  • Vasopressors
  • Surgical interventions (if applicable) 1, 3

Interventions Still Permitted

• A statement clarifying that DNR/DNE orders do not affect other treatments unless specifically noted 1
• Documentation that supplemental oxygen, intravenous fluids, pain management, antibiotics, and comfort measures will continue as appropriate 1, 2

Documentation Requirements

• Written documentation is mandatory - oral DNR orders are not acceptable 1
• The rationale for DNR/DNE orders and discussions with the patient, surrogate, and family must be recorded 1, 2
• For DNR orders that refuse life-sustaining treatment, forms must explicitly state they apply even when life is at risk 2

Consent Process Best Practices

Initial Discussion

• Early discussions about end-of-life care preferences should occur before critical situations arise 2
• Discussions should include explanation of what DNR/DNE means in practical terms 4
• Avoid medical jargon and use clear, concrete language to prevent misunderstandings 4

Addressing Common Misconceptions

• Clearly explain that DNR/DNE status does not mean abandonment or substandard care 4
• Emphasize that reasonable and proper care, including all appropriate treatments not specifically refused, will continue 2
• Document that the patient/surrogate understands these distinctions 1

Signatures and Verification

• The patient's signature (if capable) or surrogate decision-maker's signature (if patient lacks capacity) 1
• Witness signatures as required by institutional policy 1
• Physician signature and date 1

Review and Renewal Procedures

Regular Review

• Include a statement indicating when the order should be reviewed (e.g., with significant change in condition) 1
• Document the process for revoking or modifying the order 1
• DNR/DNE orders should be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate 1

Special Circumstances

• For perioperative care, clarify whether DNR/DNE orders remain in effect during surgery 5
• For patients with developmental disabilities or in foster care, the same ethical principles apply as for other patients 5

Implementation Considerations

Communication with Healthcare Team

• All team members should understand the specific limitations of care and interventions still permitted 2
• DNR/DNE status should be prominently displayed in the medical record 1
• For out-of-hospital settings, a standardized form should be used to communicate DNR orders to ambulance personnel 6

Conflict Resolution

• When conflicts arise between healthcare providers and patients/families regarding DNR/DNE decisions, basic principles of negotiation and conflict resolution should be employed 5
• Support from spiritual care providers and consultants in palliative care or ethics may be helpful 5
• In rare circumstances of extreme treatment burden with no benefit beyond postponing death, it may be ethically supportable to forgo life-sustaining medical treatment without family agreement 5

Palliative Care Integration

• Aggressive care early after certain conditions (like intracerebral hemorrhage) and postponement of new DNR orders until at least the second full day of hospitalization is recommended 5
• Palliative care should be integrated regardless of DNR/DNE status 2
• Patients and families should understand that comfort measures will continue regardless of DNR/DNE status 2

By implementing this comprehensive approach to DNR/DNE consent, healthcare providers can ensure that patients' wishes are respected while providing appropriate care aligned with their goals and values.