How to document prognosis and do-not-resuscitate (DNR) orders in a patient's casesheet?

Documentation of Prognosis and DNR Orders in the Medical Record

Document prognosis discussions and DNR decisions clearly in the casesheet with specific required elements: patient capacity status, date of order, exact interventions to be withheld, interventions still permitted, detailed account of the discussion including patient values and goals, and signatures of all parties involved. 1

Essential Components for Documenting Prognosis Discussions

What Must Be Recorded About the Prognosis Conversation

• Document the actual discussion of prognosis, not just the prognosis itself—studies show prognosis documentation occurs in only 38% of cases, yet patients are 2.2 times more likely to have a DNR order when prognosis discussions are documented 2

• Record specific prognostic information shared with the patient, including timeframes and expected clinical course, while acknowledging that physician prognostic estimates are systematically overestimated 2

• Include the patient's understanding and response to the prognostic information, as patients and physicians often place different values on end-of-life issues (e.g., 92% of patients value mental awareness at end of life versus only 65% of physicians) 2

• Document the patient's personal values, goals of care, and preferences for interventions—this is frequently missed even when DNR discussions occur 1, 3

Timing Requirements for Documentation

• For advanced cancer patients: Document prognosis discussion within 1 month of new diagnosis of advanced cancer 2

• For hospital admissions: Document patient's goals or preferences for care within 48 hours of any hospital admission for patients with advanced illness 2

• For ICU admissions: Document goals of care within 48 hours of ICU admission and before mechanical ventilation 2

Essential Components for Documenting DNR Orders

Required Elements in the DNR Documentation

Patient capacity and decision-making information:

• State clearly whether the patient had capacity at the time of the DNR decision 1
• Include the date of DNR order implementation 1
• Document who participated in the discussion (patient, surrogate decision-maker, family members) 1

Specific interventions to be withheld:

• List exact interventions to be withheld: chest compressions, endotracheal intubation, mechanical ventilation, defibrillation, vasopressors 1
• Avoid vague language—DNR orders should clearly state either "full resuscitation" or "no attempt at resuscitation," not ambiguous middle ground 1

Interventions that continue:

• Explicitly state that DNR does not affect other treatments unless specifically noted 1
• List permitted interventions: supplemental oxygen, IV fluids, pain management, antibiotics, comfort measures 1
• Clarify that DNR orders carry no implications about other forms of treatment, and document other aspects of the treatment plan separately 1

Signatures and Legal Requirements

• Obtain written physician signature—oral DNR orders are not acceptable 1
• Include patient signature if the patient has capacity 1
• Include surrogate decision-maker signature if patient lacks capacity 1
• Document witness signatures 1

Critical Documentation of the Discussion Process

Record the conversation details:

• Document the rationale for the DNR order and the clinical reasoning 1
• Include specific information disclosed: nature of CPR (chest compressions, mechanical ventilation, intensive care), benefits, risks, and realistic outcomes 3
• Use numerical estimates when discussing survival probability—only 13% of physicians mention survival likelihood, and none use numerical estimates, yet this information influences patient decisions 3
• Document discussion of patient's personal values and goals of care—this occurs in only 10% of cases but is essential 3

Timing Considerations and Common Pitfalls

When NOT to Write DNR Orders

Avoid premature DNR documentation:

• Postpone new DNR orders until at least the second full day of hospitalization for conditions like intracerebral hemorrhage where early prognostication is unreliable 2, 1
• Recognize that early DNR orders become self-fulfilling prophecies—withdrawal of support and early DNR orders are independent outcome predictors that bias prognosis 2
• Provide aggressive guideline-concordant therapy initially for all patients without pre-existing advance directives 2

Review and Modification Requirements

• 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
• Review DNR orders periodically as per local protocol, particularly if the patient's condition changes 1
• Review DNR orders before surgery with the anesthesiologist, attending surgeon, and patient or surrogate 1

Special Documentation Scenarios

Perioperative DNR Suspension

• Document whether DNR orders will be suspended during procedures—this should be discussed and agreed upon with the patient prior to the procedure 1, 4
• Record that DNR orders may remain in effect during surgery depending on patient wishes and medical condition 1
• Clarify the circumstances under which the DNR order will be reinstated post-procedure 4

Transfer of Documentation

• Transfer advance directives with patients when they change venues (e.g., hospital to nursing facility, ward to ICU) 2
• Ensure DNR documentation is portable—ideal forms include written bedside orders, wallet cards, identification bracelets, or standardized forms 2

What NOT to Document

Avoid these problematic practices:

• Never document "slow codes" or token resuscitation efforts—knowingly providing ineffective resuscitative efforts is ethically inappropriate 2
• Do not use ambiguous language about limitation of resuscitation—lack of clarity complicates care 1
• Avoid documenting DNR as affecting all aggressive care—DNR specifically addresses cardiopulmonary arrest, not other interventions 1