How to manage hypotension in a patient who is Do Not Resuscitate (DNR)/Do Not Intubate (DNI)?

Management of Hypotension in DNR/DNI Nursing Home Patients

DNR/DNI status does not limit treatment of hypotension—you should actively manage low blood pressure with fluids, vasopressors, oxygen, and electrolyte replacement if these interventions align with the patient's overall care goals and would improve their quality of life. 1

Understanding DNR/DNI Limitations

• DNR/DNI orders provide only a very narrow restriction of care, specifically prohibiting chest compressions and endotracheal intubation during cardiac arrest—they do not restrict other medical treatments. 1

• These orders must be clearly distinguished from comfort-focused end-of-life care, where monitoring and aggressive interventions would not be indicated. 1

• DNR/DNI status can be temporarily suspended when surgery or invasive procedures are planned if the patient desires these interventions. 1

Initial Assessment and Stabilization

Determine the Clinical Context

• Assess whether the hypotension is symptomatic (dizziness, altered mental status, chest pain, oliguria) or asymptomatic, as this guides intervention intensity. 1

• Evaluate hemodynamic stability using blood pressure, heart rate, oxygenation, mental status, and signs of end-organ hypoperfusion. 1

• Rule out reversible causes: hypovolemia, vasovagal reactions, electrolyte disturbances, medication side effects, or arrhythmias. 1

Immediate Interventions for Symptomatic Hypotension

• Position the patient supine or in Trendelenburg to improve venous return. 1

• Administer IV fluid bolus of 1000-2000 mL normal saline if hypovolemia is suspected and the patient is not volume overloaded. 1, 2

• Monitor vital signs continuously including blood pressure, heart rate, respiratory rate, oxygen saturation, and urine output. 1, 2

Treatment Algorithm Based on Etiology

For Hypovolemic Hypotension

• Give IV crystalloid boluses (normal saline or Ringer's lactate) targeting urine output >0.5 mL/kg/hr and mean arterial pressure ≥65 mmHg. 2

• Avoid excessive fluid administration (>10 mL/kg/hr or >250-500 mL/hr) as this increases mortality without improving outcomes. 2

For Vasodilatory/Distributive Hypotension

• Initiate norepinephrine as first-line vasopressor at 0.01-0.5 μg/kg/min, titrating to maintain mean arterial pressure ≥65 mmHg. 3

• Consider adding vasopressin (up to 0.03 units/min) if norepinephrine alone fails to achieve target blood pressure. 3

• Avoid dopamine as it has inferior outcomes compared to norepinephrine in shock states. 3

For Orthostatic Hypotension (Chronic Management)

• Midodrine 2.5-10 mg orally three times daily is FDA-approved for symptomatic orthostatic hypotension when non-pharmacologic measures fail. 4

• Critical precautions with midodrine: Avoid doses within 3-4 hours of bedtime to prevent supine hypertension; monitor for bradycardia; use cautiously with renal/hepatic impairment. 4

• Non-pharmacologic measures first: compression stockings, fluid expansion (1.5-2 L daily), increased salt intake, and lifestyle modifications. 4

Monitoring and Reassessment

Essential Monitoring Parameters

• Mean arterial pressure ≥65 mmHg as the primary hemodynamic target. 2, 3

• Urine output >0.5 mL/kg/hr as a marker of adequate end-organ perfusion. 2

• Lactate clearance, mental status, and capillary refill to assess tissue oxygenation. 3

Ongoing Clinical Judgment

• Interventions are only appropriate if they align with the patient's documented care goals and would trigger treatments the patient would accept. 1

• Monitoring is not recommended when data will not be acted upon and comfort-focused care is the primary goal. 1

• Reassess treatment appropriateness every 24-48 hours based on clinical response and patient/family preferences. 1

Critical Pitfalls to Avoid

Common Misunderstandings About DNR/DNI

• Do not withhold potentially beneficial treatments based solely on DNR/DNI status—research shows providers inappropriately withhold interventions like dialysis, bronchoscopy, ICU transfer, and vasopressors from DNR/DNI patients. 5, 6

• DNR/DNI does not mean "do not treat"—26% of patients labeled "DNR/DNI" in one study had no documentation of refusing intubation for non-arrest situations, leading to inappropriate care limitations. 7

• Clarify specific treatment preferences beyond just resuscitation status, as conflating DNR with DNI creates ambiguity about acceptable interventions. 7, 8

Medication-Related Cautions

• Avoid combining midodrine with other vasoconstrictors (phenylephrine, pseudoephedrine, ephedrine) as this increases hypertension risk. 4

• Monitor for supine hypertension with midodrine, which can cause headache, cardiac awareness, pounding in ears, and blurred vision. 4

• Use caution with cardiac glycosides and midodrine as combination therapy may precipitate bradycardia or heart block. 4

Practical Implementation

For acute symptomatic hypotension in a nursing home DNR/DNI patient:

1. Position supine, administer oxygen if hypoxemic 1
2. Give 500-1000 mL IV fluid bolus if no contraindications 1, 2
3. Transfer to hospital if persistent hypotension for vasopressor initiation 3
4. Initiate norepinephrine if mean arterial pressure remains <65 mmHg despite fluids 3
5. Document that interventions align with patient's stated care goals 1

For chronic orthostatic hypotension:

1. Optimize non-pharmacologic measures first (compression stockings, hydration, salt) 4
2. Start midodrine 2.5 mg three times daily if symptoms persist 4
3. Titrate to 10 mg three times daily as tolerated, avoiding evening doses 4
4. Monitor for supine hypertension and bradycardia 4