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 is possible and appropriate after discussing goals of care with the patient, as DNR status does not preclude life-sustaining treatments like dialysis—it only addresses cardiopulmonary resuscitation during cardiac or respiratory arrest. 1

Understanding DNR vs. Treatment Limitations

The critical distinction here is that DNR specifically means no chest compressions or intubation during a cardiac arrest, but does not automatically prohibit dialysis, medications, or other interventions. 1 The American College of Critical Care Medicine explicitly states that DNR does not mean "do not treat" or withdrawal of all life-sustaining therapies. 1

Answer A is correct: Dialysis is possible after clarifying the patient's wishes regarding dialysis specifically (not "reversing" DNR, which remains in place). The patient is alert and capable of decision-making, making this a shared decision-making scenario. 1

Critical Pitfalls to Avoid

• Never obtain consent from family members when the patient is alert and capable—this violates patient autonomy and is ethically inappropriate. 1 Answer D is therefore incorrect.
• Never assume DNR means "do not treat"—these are separate decisions that must be clarified with the patient. 1 Answer B is incorrect based on this misunderstanding.
• Never ignore the patient's wishes and proceed without discussion—Answer C represents medical paternalism and is ethically and legally unacceptable. 1
• Never delay treatment while debating DNR status—the hyperkalemia (K+ = 6.0 mEq/L) requires urgent intervention regardless of code status. 1

Immediate Management of the Hyperkalemia

While clarifying the patient's wishes about dialysis, immediate temporizing measures should be initiated for this moderate hyperkalemia (6.0 mEq/L):

• Obtain an ECG immediately to assess for cardiac risk—peaked T waves, widened QRS, or prolonged PR interval indicate urgent need for cardiac membrane stabilization. 1
• If ECG changes are present, administer IV calcium gluconate (15-30 mL of 10% solution over 2-5 minutes) for cardiac protection, with effects lasting 30-60 minutes. 1, 2
• Administer insulin 10 units IV with 25g dextrose to shift potassium intracellularly, with onset in 15-30 minutes and duration of 4-6 hours. 1, 3
• Consider nebulized albuterol 20 mg in 4 mL as adjunctive therapy for intracellular potassium shifting. 3

Essential Conversation with the Patient

The physician must have an open discussion with this alert patient about:

• Whether she wishes to continue dialysis for symptom management and quality of life, separate from her DNR status. 1
• The natural history without dialysis: death typically occurs within 7-14 days in ESRD patients who discontinue dialysis. 1
• That hyperkalemia at this level (6.0 mEq/L) can cause life-threatening arrhythmias and sudden death. 4, 5
• If the patient specifically declines dialysis, then conservative management with palliative care becomes appropriate, focusing on symptom control with potassium binders and comfort measures. 1

If Patient Agrees to Dialysis

• Hemodialysis is the most effective and reliable method for potassium removal in ESRD patients, reducing K+ from 5.63 to 4.29 mEq/L within one hour. 6, 3
• Dialysis should be performed urgently given the moderate hyperkalemia and risk of cardiac complications. 5
• Initiate chronic potassium management with newer potassium binders (patiromer or sodium zirconium cyclosilicate) to prevent recurrent hyperkalemia between dialysis sessions. 1, 3

If Patient Declines Dialysis

• All patients who decline dialysis should receive integrated palliative care with focus on symptom management. 1
• Temporary potassium control using potassium binders (patiromer 8.4g daily or sodium zirconium cyclosilicate 10g three times daily for 48 hours) can provide comfort by preventing arrhythmias. 1, 3
• Conservative management becomes the priority, with symptom control as the primary goal. 1

Legal and Ethical Framework

The American Medical Association emphasizes that open communication about treatment goals is essential—the patient's DNR status indicates she wants to avoid aggressive resuscitation, but this must be distinguished from her wishes regarding ongoing supportive care like dialysis. 1 Since she is alert and capable, she alone has the legal and ethical authority to make this decision—not her family members. 1