DNR and DNI Orders in the ICU
When to Consider DNR/DNI Orders
Aggressive full care should be provided early after ICU admission, and new DNR orders should be postponed until at least the second full day of hospitalization for most critically ill patients, particularly those with conditions like intracerebral hemorrhage where early prognostication is unreliable. 1, 2
Timing Considerations
Avoid early DNR orders in the first 24-48 hours unless the patient has pre-existing advance directives, as early care limitations become self-fulfilling prophecies of poor outcome due to inaccurately pessimistic prognostication 1, 2
Early DNR orders (within the first day) have been identified as independent predictors of mortality, likely because they proxy for overall lack of aggressiveness of care rather than just withholding CPR 1
Current outcome prediction models fail to account for the influence of withdrawal of support and early DNR orders, creating bias in prognostication 1
Clinical Scenarios Where DNR/DNI Should Be Considered
DNR/DNI orders are appropriate when:
The patient has advanced age or terminal condition with short life expectancy, based on patient/family preference and clinical judgment of experienced providers 1
The patient is irreversibly ill or not responsive to maximal therapy 3
CPR would not prevent impending death to a reasonable degree of medical certainty (e.g., multiorgan failure with progressive metastatic cancer) 1
The intervention cannot accomplish the intended physiological goals (futile intervention) 1
The patient has transitioned to comfort-focused end-of-life care 1
Who Should Make the Decision
The decision-making process should involve:
Seeking patient or family preferences regarding aggressive resuscitation measures for patients admitted to the hospital 1
Consultation with other physicians, patients, and their families - implementation of formal DNR policies enhances this communication 3
Clinical judgment of experienced providers regarding expectation of outcome 1
For patients lacking capacity (which represents 88% of DNR cases in ICU), surrogate decision-makers must be involved 3
Critical Distinctions About DNR/DNI Status
What DNR/DNI Does NOT Limit
DNR or DNI status does not limit the use of other treatments and should not result in withdrawal of appropriate medical care: 1, 4
- Vasopressors can still be administered 1, 4
- Oxygen support continues 1, 4
- Electrolyte replacement is appropriate 1
- Supplemental oxygen, IV fluids, pain management, and antibiotics remain indicated 4, 2
- Comfort measures should be maximized 4, 2
When DNR/DNI Can Be Suspended
DNR/DNI status can be suspended when surgery or invasive procedures are planned, after discussion and agreement with the patient prior to the procedure 1, 4, 5
Perioperative cardiac arrests have substantially higher survival rates due to reversible procedural causes, making suspension of DNR orders usually appropriate during this period 5
Documentation Requirements
Essential components that must be documented include: 4, 2
- Clear statement of patient's capacity at time of decision-making 4, 2
- Date of DNR/DNI order implementation 4, 2
- Specific interventions to be withheld (chest compressions, endotracheal intubation, mechanical ventilation, defibrillation, vasopressors) 4, 2
- Interventions that remain permitted 4, 2
- Record of discussion with patient and/or surrogate decision-maker, including patient's values, goals, and preferences 4, 2
- Patient and/or surrogate signatures with witness signatures 4
- Review and renewal information 4
The documentation must be written - oral DNR orders are not acceptable 4
Monitoring Considerations
Arrhythmia monitoring may be considered in DNR/DNI patients if findings would trigger interventions consistent with patient wishes (e.g., rate control if symptomatic), but monitoring is not recommended when data will not be acted upon and comfort-focused care is the goal 1
Common Pitfalls to Avoid
Self-fulfilling prophecies: Early DNR orders lead to less aggressive care, which then results in the predicted poor outcome 1, 2
Vague language: Avoid unclear limitation orders; specify exactly which interventions are withheld 2
Assuming DNR means withdrawal of all care: 50% of DNR patients in ICU continue to receive other therapies, and one study found a DNR patient who recovered and was discharged from hospital 3
Failure to review: DNR orders should be reviewed periodically as per local protocol, particularly if the patient's condition changes 4
Inadequate prognostication discussion documentation: Document the actual discussion of prognosis, not just the prognosis itself, as this significantly affects DNR decision-making 2