What is the appropriate action for an alert female patient with a history of severe Multiple Sclerosis (MS) and recently diagnosed End-Stage Renal Disease (ESRD), who has a Do Not Resuscitate (DNR) order and presents with hyperkalemia?

Management of Hyperkalemia in an Alert ESRD Patient with DNR Status

Dialysis should be offered to this patient immediately, as a DNR order does not preclude dialysis or other life-sustaining treatments—it only addresses resuscitation in the event of cardiopulmonary arrest. 1

Understanding DNR vs. Treatment Limitations

A DNR order is not equivalent to withholding all medical interventions. The distinction is critical:

• DNR specifically means: No chest compressions, no defibrillation, and no intubation for cardiopulmonary arrest 1
• DNR does NOT mean: Withholding dialysis, medications, procedures, or other medical treatments 1
• This patient is alert and has decision-making capacity, which means she can consent to or refuse specific treatments independently 1

Immediate Management of Hyperkalemia

Dialysis is the definitive treatment for hyperkalemia in ESRD patients and should be offered urgently given the potassium level of 6.0 mEq/L. 2, 3

Acute Stabilization Measures (while arranging dialysis):

• Intravenous calcium to stabilize the myocardium and prevent cardiac arrhythmias 2
• Intravenous insulin with dextrose to shift potassium intracellularly 2
• Nebulized albuterol for additional intracellular potassium shifting 2
• Obtain ECG to assess for hyperkalemia-related cardiac changes, as 36.7% of severe hyperkalemia cases show typical ECG findings 4

Shared Decision-Making Process

The patient must be fully informed about her treatment options through shared decision-making, which is the standard of care for ESRD patients: 1

Required Discussion Points:

• Prognosis and life expectancy with and without dialysis 1
• Available treatment options: hemodialysis, peritoneal dialysis, conservative management, or time-limited trial of dialysis 1
• Risks of untreated hyperkalemia: cardiac arrhythmias, cardiac arrest, and death (mortality rate of 30.7% with severe hyperkalemia) 4
• Quality of life implications of each option 1

Patient Autonomy:

• If the patient consents to dialysis, proceed immediately 1
• If the patient refuses dialysis after being fully informed, her decision must be respected as she has decision-making capacity 1
• The DNR order remains in effect regardless of whether she accepts dialysis 1

Common Pitfalls to Avoid

Do NOT assume DNR means "do not treat"—this is a fundamental misunderstanding that can lead to inappropriate withholding of beneficial interventions. 1

Do NOT seek consent from family members when the patient is alert and has decision-making capacity—this violates patient autonomy. 1

Do NOT reverse the DNR order to provide dialysis—these are separate decisions. 1

If Dialysis is Declined

Should the patient refuse dialysis after informed consent, palliative care must be provided: 1

• Hospice involvement for symptom management and end-of-life care 5
• Symptom control using validated tools (ESAS-R or iPOS-R) 5
• Continued medical management of hyperkalemia symptoms with medications adjusted for renal function 5
• Bereavement support for family members 1

Documentation Requirements

Document the following in the medical record: 1

• Discussion of prognosis, treatment options, and patient's understanding
• Patient's decision regarding dialysis (acceptance or refusal)
• Confirmation that DNR status remains unchanged
• Date and time of all discussions

The correct answer is A: Dialysis is possible without reversal of DNR, though the phrasing is imprecise—dialysis requires patient consent, not DNR reversal, as these are independent decisions.