DNR Order Management for Patients with Severe Progressive Neurological Conditions
DNR orders should be reviewed periodically according to local institutional protocol, particularly when the patient's clinical condition changes, as they are not permanent lifetime orders. 1
Core Management Principle
DNR orders require active physician review and documentation—they are medical orders, not permanent directives that remain "valid for life." 1 The American Heart Association explicitly states that these orders must be reviewed periodically as per local protocol, especially when patient conditions change. 1, 2
When to Review DNR Orders
Trigger points for mandatory review include:
- Significant changes in clinical condition - Any deterioration or improvement in the patient's neurological status warrants reassessment 1
- Before any surgical or procedural intervention - The DNR status must be explicitly addressed and documented before procedures 3
- At regular intervals per institutional protocol - Most institutions have specific timeframes (commonly ranging from immediate review to periodic assessment) 1
- Transfer between healthcare settings - DNR orders from other facilities require re-evaluation and new documentation at the receiving facility 2
Documentation Requirements for Each Review
Each review must include:
- Documented discussion with family/surrogate decision-makers about current clinical status and goals of care 1
- Clear notation of the rationale for continuing, modifying, or revoking the DNR order 1
- Specific instructions about which interventions are withheld and which continue 1, 2
- Attending physician signature with a note explaining the decision 3
Critical Distinction: DNR Does Not Mean "Do Not Treat"
A common and dangerous pitfall is assuming DNR means withholding all aggressive care. 4 A DNR order does not automatically preclude interventions such as:
- Parenteral fluids and nutrition 3, 2
- Oxygen therapy 3, 2
- Analgesia and sedation 3, 2
- Antiarrhythmics and vasopressors 3, 2
- Antibiotics 3
- Blood products 3
These interventions should continue unless explicitly excluded in the order. 4, 3
Special Considerations for Neurological Conditions
For patients with severe progressive neurological conditions, timing of DNR discussions is particularly important. In the context of acute neurological catastrophes like intracerebral hemorrhage, the American Heart Association recommends postponing new DNR orders until at least the second full day of hospitalization. 4 This is because:
- Early DNR orders (within 24-48 hours) create self-fulfilling prophecies of poor outcome 4
- Current prognostic models are biased by failure to account for early care limitations 4
- The overall aggressiveness of care at a hospital independently predicts patient outcomes 4
However, patients with pre-existing DNR orders are not included in this recommendation for delayed DNR implementation. 4
Ongoing Communication Requirements
The American Academy of Pediatrics emphasizes that ongoing communication with families is critical, as their understanding and wishes may evolve over time. 1 This principle applies equally to adult patients with progressive conditions. Each review should reassess whether the family's goals of care have changed as the disease trajectory becomes clearer.
Answer to the Multiple Choice Question
None of the provided options (A-D) accurately reflects guideline-based practice. DNR orders are not "valid for life" (Option A is incorrect), nor are they reviewed on fixed schedules like annually, every 3 months, or every 6 months (Options B, C, D are all incorrect). 1
The correct approach is condition-triggered and protocol-based review: DNR orders must be reviewed when clinical conditions change and at intervals specified by local institutional protocol, with mandatory review before any procedures. 1, 2 The specific timeframe varies by institution and clinical context, but the key principle is that reviews are triggered by clinical events and institutional policy, not arbitrary calendar intervals.