Prioritize Documented Patient Preference for DNR
The team must prioritize the documented patient preference regarding DNR (Option D), as this represents the patient's autonomous decision and legally binding medical order that supersedes family wishes when there is uncertainty about current preferences. 1, 2
Legal and Ethical Framework
The American Heart Association explicitly states that DNR orders must be completed, signed, and dated by a physician after documented discussion with the patient, and these orders carry legal weight that must be honored. 1 When a patient has documented their DNR preference, this becomes a physician's order that healthcare teams are obligated to follow, regardless of family disagreement. 2
Why Patient Autonomy Takes Precedence
- Advance directives and documented patient preferences ensure that the patient's wishes guide care even when the patient cannot currently communicate. 1
- Studies demonstrate that honoring advance care planning is associated with better quality of life and better bereavement adjustment by caregivers, even when families initially disagree. 1
- The patient's documented DNR wish reflects their personal values about end-of-life care, which should not be overridden by family hopes for recovery that may not align with medical reality. 1
Addressing Team Uncertainty
When the team is "uncertain about the true wishes," they should:
- Review all documented advance care planning, including living wills, powers of attorney, MOLST/POLST forms, and any written DNR orders in the medical record. 1, 2
- Verify that the DNR documentation includes: the patient's capacity at time of decision-making, date of implementation, specific interventions to be withheld, and record of discussion with the patient. 2, 3
- If documentation exists showing the patient expressed DNR wishes while having decision-making capacity, this must be honored. 1, 2
Managing Family Conflict
For this patient with end-stage lung cancer and respiratory failure, the family's belief in recovery does not override documented patient preferences:
- Palliative care consultation should be obtained to assist in conflict resolution when the patient, family, and medical team do not agree. 1
- The team should have frank discussions with the family about the probability of surviving cardiac arrest in this clinical context, as most patients understand prognostic information and make informed decisions accordingly. 1
- It is critical to explain to the family that DNR orders do not limit other appropriate medical care—the patient can still receive oxygen, IV fluids, antibiotics, pain management, and comfort measures. 2, 4
Critical Distinction About DNR Orders
A common pitfall is assuming DNR means "do nothing." The team must clarify:
- DNR status does not affect other treatments unless specifically noted—aggressive medical management continues for reversible conditions. 2, 4
- The DNR order specifically addresses cardiopulmonary resuscitation when the heart or breathing stops, not overall medical care. 2
When Documentation Is Truly Absent or Ambiguous
Only if there is genuinely no documented patient preference (not the case described here), then the team should:
- Attempt to determine the patient's current wishes if they have any capacity to communicate. 1
- Consult with the legal surrogate decision-maker (not just "family") to make decisions based on substituted judgment—what the patient would have wanted. 1, 2
- Never proceed with CPR immediately (Option B) without first attempting to clarify documented wishes, as unwanted resuscitation violates patient autonomy and causes harm. 1
In this specific scenario with documented DNR wishes, the answer is unequivocally Option D—the team must honor the documented patient preference, provide palliative care consultation for family conflict resolution, and continue all other appropriate medical care. 1, 2