Is a chest X-ray (CXR) still indicated for a Do Not Resuscitate (DNR) patient in a nursing home with a focus on comfort care?

Chest X-Ray in DNR Comfort Care Nursing Home Patients

For a DNR nursing home patient focused on comfort care, chest X-ray should only be obtained if the result would change symptom management or clarify a diagnosis that impacts comfort measures—not as routine practice. 1

Core Principle: Goals of Care Drive Imaging Decisions

The decision to obtain a chest X-ray must align with the patient's comfort-focused goals, not with standard diagnostic protocols. 2 DNR status does not automatically mean "no diagnostics," but rather that interventions should serve the patient's stated goals of comfort and quality of life. 3

When CXR May Be Appropriate in Comfort Care

Consider chest X-ray if:

• Diagnostic uncertainty affects symptom management: When you cannot distinguish between pneumonia, heart failure, or pleural effusion, and the distinction would change your approach to dyspnea or pain management. 1

• Guiding specific comfort interventions: For example, identifying a large pleural effusion that could be drained for symptom relief, or confirming pneumonia to justify targeted antibiotic therapy if consistent with goals of care. 1

• Family or patient requests clarification: When understanding "what's happening" provides psychological comfort, even without changing treatment. 2

When CXR Should Be Avoided

Do not obtain chest X-ray when:

• Management will remain purely symptomatic regardless of findings: If you plan to treat dyspnea with morphine and oxygen regardless of whether pneumonia, heart failure, or both are present, the X-ray adds no value. 1

• Patient is too frail for positioning: The discomfort and effort required for portable radiography may outweigh any benefit in a comfort-focused patient. 1

• Results would not influence the decision to remain in the nursing home: If the patient and family have clearly stated they want to remain in place with comfort measures only, identifying multilobe pneumonia or other high-risk findings becomes irrelevant. 1

Evidence Context and Practical Considerations

The IDSA guidelines emphasize that while chest X-ray is the most reliable method for documenting pneumonia in nursing home residents, there are no studies showing improved outcomes from obtaining chest X-rays in this population. 1 This is particularly relevant for comfort care patients where outcome priorities shift from mortality reduction to symptom control.

Critical caveat: Research shows that 52% of nursing home chest X-rays show very low likelihood of pneumonia, 18% are ambiguous, yet antibiotics are prescribed in 71% of ambiguous cases and 34% of negative cases. 4 This suggests chest X-rays in nursing homes often drive unnecessary interventions rather than clarifying management.

Practical Algorithm

1. Ask first: "Will the X-ray result change what we do for this patient's comfort?"

   • If yes → Consider obtaining CXR 1
   • If no → Proceed with clinical diagnosis and symptom management 4

2. Use pulse oximetry instead when possible: Oxygen saturation <90% has 80% sensitivity and 91% specificity for pneumonia in nursing home residents and can guide oxygen therapy without radiation or transport burden. 1

3. Treat clinically when diagnosis is clear: Fever, tachypnea >25 breaths/min, new cough with purulent sputum—this clinical picture justifies treatment without radiographic confirmation in a comfort care patient. 1

4. Document your reasoning: Clearly note whether CXR was deferred based on goals of care to avoid misinterpretation by other providers who may equate DNR with "do nothing." 3

Common Pitfall to Avoid

Do not reflexively order chest X-rays because "that's what we always do for pneumonia." 5 In ICU settings, 61% of units have moved away from routine daily chest X-rays to on-demand imaging without negative outcomes. 1 This principle applies even more strongly to comfort care nursing home patients where the burden of testing must be weighed against limited benefit. 1