What is the appropriate action for a patient with end-stage renal disease (ESRD) and a Do Not Resuscitate (DNR) order who has hyperkalemia?

DNR Status Does Not Preclude Dialysis for Life-Threatening Hyperkalemia

Dialysis can and should be performed for this alert patient with ESRD and hyperkalemia despite DNR status, as DNR only restricts resuscitation measures, not other life-sustaining treatments like dialysis. The correct answer is that dialysis is possible without reversing DNR status.

Understanding DNR in the Context of Dialysis

DNR status provides only a very limited narrowing of care and should be clearly delineated from comfort-focused end-of-life care. 1

• DNR or DNI status does not limit the use of other treatments including electrolyte replacement, oxygen support, or vasopressors 1
• Monitoring and treatment in patients with DNR status is indicated if it would guide therapy congruent with the patient's overall care wishes 1
• DNR status can be suspended when surgery or invasive procedures are planned 1

When Dialysis Should Be Provided

The Renal Physicians Association and American Society of Nephrology guidelines clearly state that advance directives should be honored, but dialysis is appropriate when the patient with decision-making capacity has not refused it 1

It is appropriate to withhold or withdraw dialysis ONLY for: 1

• Patients with decision-making capacity who, being fully informed and making voluntary choices, refuse dialysis or request discontinuation
• Patients who no longer possess decision-making capacity who have previously indicated refusal of dialysis in an advance directive
• Patients whose properly appointed legal agents refuse dialysis or request discontinuation
• Patients with irreversible, profound neurologic impairment lacking signs of thought, sensation, purposeful behavior, and awareness

Critical Distinction in This Case

This patient is alert and has decision-making capacity - the DNR order addresses only resuscitation preferences, not dialysis decisions 1

• The patient has not refused dialysis; they have only requested DNR status 1
• Shared decision-making should involve the patient and physician to explain treatment options, including dialysis for acute complications like hyperkalemia 1
• With potassium of 6.0 mEq/L, this represents a life-threatening but treatable complication 2, 3

Management Approach for Hyperkalemia in ESRD

Hyperkalemia is one of the two leading reasons for emergency dialysis among ESRD patients and is associated with cardiac arrhythmia and sudden death 2, 4

Immediate Actions:

• Nondialytic management should be instituted immediately as initial therapy while discussing dialysis options 2
• This includes calcium for cardiac membrane stabilization, insulin/glucose, and beta-agonists for potassium shifting 2
• Dialysis provides definitive treatment of hyperkalemia among ESRD patients 2

Decision-Making Process:

• Fully explain the diagnosis, prognosis, and treatment options to the patient, including the option of dialysis for this acute complication 1
• Discuss that hyperkalemia at this level poses immediate cardiac risk 4, 3
• The patient's choice should be informed and voluntary 1

Common Pitfalls to Avoid

Do not assume DNR means "do not treat" - this is a fundamental misunderstanding that can lead to withholding beneficial, life-sustaining interventions 1

• Never ignore the patient's wishes - but ensure you understand what those wishes actually are (DNR ≠ refusal of all treatment) 1
• Do not seek consent from relatives when the patient has decision-making capacity - the alert patient makes their own decisions 1
• Reversing DNR is unnecessary and inappropriate - dialysis is not a resuscitation measure 1

Documentation Requirements

These discussions should be documented and dated 1

• Document the patient's understanding of their hyperkalemia and cardiac risk
• Record the patient's decision regarding dialysis for this acute complication
• Clarify that DNR status remains in effect during dialysis if that is the patient's wish 1