What is the appropriate management for a patient with End-Stage Renal Disease (ESRD) and hyperkalemia, who has a Do Not Resuscitate (DNR) order?

Management of Hyperkalemia in an Alert ESRD Patient with DNR Status

Dialysis can and should be performed for this patient with hyperkalemia (K+ 6.0 mEq/L) despite the DNR order, as DNR does not preclude life-sustaining treatments like dialysis. The correct answer is that dialysis is possible and appropriate without reversing the DNR (Option A is misleading—no "reversal" is needed; the DNR remains in place).

Understanding DNR vs. Treatment Limitations

A DNR order specifically addresses cardiopulmonary resuscitation in the event of cardiac or respiratory arrest—it does NOT prohibit other medical treatments, including dialysis. 1

• The patient is alert and capable of expressing wishes, making shared decision-making essential in this scenario 1
• DNR status does not automatically mean "do not treat" or withdrawal of all life-sustaining therapies 1
• The critical distinction: DNR means no chest compressions or intubation during a cardiac arrest, but does not preclude dialysis, medications, or other interventions 1

Immediate Management of Hyperkalemia (K+ 6.0 mEq/L)

This potassium level of 6.0 mEq/L represents moderate hyperkalemia requiring urgent intervention 1, 2

Step 1: Assess for Cardiac Risk

• Obtain an ECG immediately to check for peaked T waves, flattened P waves, prolonged PR interval, or widened QRS complex 2, 3
• If ECG changes are present, administer IV calcium gluconate 10-30 mL of 10% solution over 2-5 minutes for cardiac membrane stabilization 2, 4
• Calcium works within 1-3 minutes but is temporary (30-60 minutes) and does NOT lower potassium 2, 4

Step 2: Shift Potassium Intracellularly

• Administer insulin 10 units regular IV with 25-50g dextrose (onset 15-30 minutes, duration 4-6 hours) 2, 3
• Add nebulized albuterol 10-20 mg in 4 mL (onset 15-30 minutes, duration 2-4 hours) 2, 3
• Do NOT use sodium bicarbonate unless metabolic acidosis is documented (pH <7.35, bicarbonate <22 mEq/L)—it is ineffective without acidosis 1, 2, 5

Step 3: Remove Potassium from the Body

• Hemodialysis is the most effective and reliable method for potassium removal in ESRD patients and is the definitive treatment 2, 6, 7
• Loop diuretics (furosemide 40-80 mg IV) are ineffective in anuric ESRD patients 2
• Newer potassium binders (patiromer or sodium zirconium cyclosilicate) can be initiated for chronic management but have delayed onset (1-7 hours) 1, 2

The Ethical and Legal Framework

The patient's autonomy must be respected through shared decision-making, but DNR does not equal refusal of all treatment 1

• Open communication with the patient about dialysis options is essential—discuss whether she wishes to continue dialysis for symptom management and quality of life 1
• If the patient has expressed wishes to avoid dialysis specifically (not just DNR), then conservative management with symptom control becomes appropriate 1
• Taking consent from a relative (Option D) is inappropriate when the patient is alert and capable of making her own decisions 1
• Ignoring the patient's wishes (Option C) violates autonomy and is ethically unacceptable 1

Conservative Management if Dialysis is Declined

If after discussion the patient declines dialysis, focus shifts to palliative symptom management 1:

• Control symptoms such as fatigue, dyspnea, anxiety, pruritus, and nausea with appropriate medications 1
• Potassium binders (patiromer 8.4g daily or SZC 10g three times daily for 48 hours then 5-15g daily) can provide temporary control 1, 2
• All patients who decline dialysis should receive integrated palliative care 1
• Discontinuation of dialysis in ESRD typically leads to death within 7-14 days, and symptom management becomes the priority 1

Critical Pitfalls to Avoid

• Never assume DNR means "do not treat"—these are separate decisions 1
• Never obtain consent from family members when the patient is alert and capable 1
• Never delay treatment while debating DNR status—address the hyperkalemia emergently while clarifying goals of care 2
• Do not use sodium bicarbonate without documented metabolic acidosis—it wastes time and is ineffective in renal failure 1, 2, 5
• Remember that calcium, insulin, and beta-agonists are temporizing only—dialysis is required for definitive potassium removal in ESRD 2, 6

Recommended Approach

1. Stabilize the patient emergently with calcium (if ECG changes), insulin/glucose, and albuterol 2, 3
2. Engage in immediate shared decision-making with the alert patient about dialysis—explain that DNR does not preclude this treatment 1
3. If the patient consents to dialysis, proceed urgently—this is the definitive treatment for hyperkalemia in ESRD 2, 6
4. If the patient declines dialysis after informed discussion, initiate palliative care with symptom management and potassium binders for temporary control 1, 2
5. Document the conversation and the patient's wishes clearly in the medical record 1