Where should a Do Not Resuscitate (DNR) order be signed and stored for hemodialysis patients?

DNR Documentation for Hemodialysis Patients

DNR orders for hemodialysis patients must be signed as written medical orders in the patient's medical record by a licensed physician, and ideally should also exist in portable formats (wallet cards, identification bracelets, or standardized state forms) to ensure continuity across care settings. 1, 2

Required Documentation Location and Format

Primary Documentation Site

• The DNR order must be written, signed, and dated by a physician in the patient's medical record - oral DNR orders are explicitly not acceptable 1
• The order should be completed after documented discussion with the patient and/or family or legal representative 1
• This is not a "legal place" separate from the dialysis unit, but rather part of the standard medical documentation within the healthcare facility 1

Portable Documentation (Strongly Recommended)

• DNR documentation should be portable using standardized forms such as written bedside orders, wallet cards, identification bracelets, or state-specific standardized forms to ensure the patient's wishes are honored across different settings 3, 2
• This is particularly critical for hemodialysis patients who transition between dialysis units, home, emergency departments, and hospitals 2, 4
• Statewide portable DNR orders improve continuity among providers and organizations, ensuring patients' wishes are followed regardless of setting 2

Essential Documentation Components

The DNR order must include 1, 3:

• Clear statement of patient's capacity at the time of decision-making
• Date of DNR order implementation
• Specific interventions to be withheld (chest compressions, endotracheal intubation, mechanical ventilation, defibrillation, vasopressors)
• Interventions that remain permitted (supplemental oxygen, IV fluids, pain management, antibiotics, comfort measures)
• Record of discussion with patient and/or surrogate decision-maker, including patient's values, goals, and preferences
• Signatures: patient's signature (if capable), surrogate decision-maker signature (if patient lacks capacity), and witness signatures 1

Critical Considerations for Hemodialysis Patients

Facility Variation Issues

• Research shows significant inter-facility variation in DNR orders among hemodialysis patients (ranging from 1% to 26% within Ontario alone), highlighting inconsistent practices that need standardization 5
• Only 10% of Canadian hemodialysis patients with documented advance care directives had DNR orders, suggesting potential underutilization 5

Continuity of Care Problems

• A major pitfall occurs at hospital discharge: among patients with inpatient DNR orders who were discharged home, only 1 of 5 families had a written DNR order at home, creating risk for unwanted resuscitation 4
• Physicians should discuss future resuscitation procedures with hemodialysis patients who have DNR orders at the time of any care transition 4
• Protocols should be developed so that paramedics can honor DNR wishes in the prehospital setting 4

Common Pitfalls to Avoid

• Lack of portable documentation: The DNR order in the dialysis unit medical record does not automatically transfer to other settings 2, 4
• Failure to review periodically: DNR orders should be reviewed as per local protocol, particularly if the patient's condition changes 1
• Inadequate scope clarification: The order must explicitly state that DNR status does not limit other appropriate treatments (vasopressors, oxygen support, electrolyte replacement, antibiotics) unless specifically noted 6, 1
• Color-coded wristband confusion: If using color-coded wristbands for DNR identification, be aware that 8 different color schemes exist across hospitals, creating potential for errors during transfers 7

Practical Implementation

For hemodialysis patients, implement a dual documentation system: 1, 3, 2

1. Primary order: Written physician order in the dialysis unit medical record with all required components
2. Portable documentation: State-standardized form, wallet card, or medical alert bracelet that travels with the patient

This approach addresses both the legal requirement for physician-signed orders and the practical reality that hemodialysis patients frequently move between care settings where their wishes must be immediately identifiable.