What is the approach to DNR (Do Not Resuscitate) consent for a patient with pancreatic cancer?

DNR Consent for Pancreatic Cancer

For patients with pancreatic cancer, DNR consent should be approached through early, comprehensive goals-of-care discussions that include assessment of patient values and preferences, clear documentation of specific interventions to be withheld, and integration with palliative care services—not as an isolated decision but as part of ongoing advance care planning that begins at diagnosis. 1, 2

Initial Approach to DNR Discussions

Timing and Context

• Begin goals-of-care conversations at the first visit, including full assessment of symptom burden, psychological status, and social supports, as this establishes the framework for all subsequent decisions including DNR status. 1
• Discuss patient preferences and personal goals of care early, asking what makes life meaningful to them, their priorities, and what they value more—extension of life versus maintenance of quality of life. 1
• Provide realistic hope within honest, supportive discussions about prognosis, even when short, as patients deserve to know their medical team is working toward their goals. 1

Essential Pre-DNR Discussions

• Explain all potential treatment options and possible adverse effects so patients understand benefits and drawbacks before making DNR decisions. 1
• Clarify that palliative care referral is NOT synonymous with hospice or DNR—palliative care provides support alongside active treatment and should be offered regardless of stage or prognosis. 1
• Address quality-of-life issues specific to pancreatic cancer including dietary concerns, pain management, and fatigue, as these significantly impact decision-making. 1

Required Components of DNR Consent Documentation

Patient Information and Capacity Assessment

• Document the patient's decision-making capacity at the time of the DNR order and the date of implementation. 2
• If the patient lacks capacity, document the medical power of attorney's legal authority and their understanding that decisions must be based on the patient's known values, goals, and preferences. 3

Specific Interventions to Withhold

The DNR order must explicitly state which interventions are to be withheld: 2

• Cardiopulmonary resuscitation (CPR)
• Endotracheal intubation and mechanical ventilation
• Vasopressors (must be explicitly stated)

Interventions That Continue

Critical clarification: DNR orders do NOT automatically limit other treatments. The consent must specify that the following may continue unless specifically refused: 2, 4

• Supplemental oxygen
• Intravenous fluids
• Pain management and comfort measures
• Antibiotics
• Pancreatic enzyme replacement therapy
• Nutritional support
• All other appropriate medical care

Documentation of Discussion Process

• Record the discussion with the patient and/or surrogate decision-maker, including the patient's values, goals, and preferences that informed the decision. 2
• Document the rationale for the DNR order and all discussions with patient, surrogate, and family members. 2
• Include cultural, religious, or spiritual factors influencing the decision. 3

Required Signatures

• Patient signature (if capable) 2
• Surrogate decision-maker signature (if patient lacks capacity) 2
• Witness signatures 2
• Physician signature—oral DNR orders are NOT acceptable; they must be written 2

Review and Modification Provisions

• Include a statement indicating when the order should be reviewed (particularly with significant change in condition). 2
• Document the process for revoking or modifying the order. 2
• For surgical patients, DNR orders should be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate. 2

Critical Legal and Scope Clarifications

Legal Requirements

• Forms must explicitly state they apply even when life is at risk. 2
• The order must be written, witnessed, and clearly state applicability to life-sustaining treatment. 2
• A licensed physician's order is necessary—this is a legal requirement. 2

Scope Statements

• Include a clear statement that DNR orders are specific medical orders, NOT advance directives. 2, 4
• Explicitly state that DNR status does not limit other appropriate treatments unless specifically noted. 2
• Note that the order can be suspended for procedures when appropriate and consistent with patient goals. 2

Common Pitfalls to Avoid

Communication Errors

• Never equate DNR with "giving up" or withdrawal of all care—this is the most common misunderstanding that prevents appropriate DNR discussions. 1
• Avoid delaying DNR discussions until crisis situations; early conversations before critical events lead to better decision-making. 4
• Don't assume family members understand the patient's wishes—explicitly explore this and document potential conflicts. 3

Documentation Failures

• Lack of clarity in limitation orders complicates care—be specific about what is withheld versus what continues. 2
• Failing to document the patient's capacity at the time of decision-making creates legal vulnerability. 2
• Not reviewing DNR orders periodically as the patient's condition changes. 2, 4

Process Errors

• Proceeding without ensuring both patient AND caregiver have accurate prognostic understanding—when both understand prognosis of ≤12 months, 70.7% complete DNR orders versus only 31.6-38.9% when one or both lack understanding. 5
• Not involving palliative care early, which facilitates addressing non-treatment-related issues that affect DNR decisions. 1

Special Considerations for Pancreatic Cancer

Disease-Specific Context

• Patients with metastatic pancreatic cancer have high symptom burden at diagnosis, making early DNR discussions particularly relevant. 1
• For patients presenting with extensive disease, too ill to tolerate treatment, or with progressive disease without reasonable further anticancer treatment, hospice discussion and possible referral should occur alongside DNR conversations. 1

Support Resources

• Offer decision-making tools and urge patients to write down questions between appointments. 1
• Refer to Cancer.net and Pancreatic Cancer Action Network for additional support. 1
• Have a support person present (nurse, chaplain, social worker) during DNR discussions to assist the family. 2

Conflict Resolution

• When conflicts arise between healthcare providers and patients/families regarding DNR decisions, employ basic principles of negotiation and conflict resolution with support from spiritual care providers and consultants in palliative care or ethics. 2
• If family disagrees with the medical team, obtain ethics consultation to resolve conflicts. 2