What are the next steps for a patient with a Do Not Resuscitate (DNR) order who has been declared deceased?

Management of a Deceased Patient with DNR Status

When a patient with a DNR order has been declared deceased, immediately provide compassionate after-death care to the family, complete required documentation including the death certificate, and consider organ donation if appropriate and consistent with the patient's wishes.

Immediate Post-Death Actions

Family and Body Care

• Provide the family time with the body in a respectful, culturally sensitive manner 1
• Remove tubes, drains, lines, and foley catheter unless an autopsy is planned 1
• If family members were not present at the time of death, inform them promptly 1
• Allow a brief respectful period (typically about 5 minutes) for relatives to have additional time with the patient before any transfer 1

Clinical Documentation Requirements

• Complete the death certificate and all necessary forms for the funeral director 1
• Document the patient's status as "dead" at the end of the clinical encounter 1
• Ensure all advance care planning documentation, including the DNR order, is properly filed in the medical record 1
• Note the time of death certification, which should occur at minimum 5 minutes after cardiorespiratory arrest to ensure autoresuscitation does not occur 1

Organ Donation Considerations

Assessment for Donation Eligibility

• Address survivor concerns about organ donation and/or autopsy as part of immediate after-death care 1
• If organ donation was previously discussed and the patient meets criteria for donation after cardiac death (DCD), the process should proceed according to established protocols 1
• The dignity, well-being, and comfort of the dying patient remain paramount, and relatives can stop the donation process at any time without reason 1

Critical Timing for DCD

• Death must be certified by confirming absence of cardiac output and respiration, lack of response to supraorbital pressure, and absence of pupillary and corneal reflexes 1
• A waiting period of 2-5 minutes after cardiorespiratory arrest is required before death declaration, depending on institutional policy 1
• No drugs (such as heparin) may be administered to facilitate organ donation until death has been certified, as this would not be in the patient's interest 1

Communication and Support

Healthcare Team Notification

• Inform all other healthcare providers involved in the patient's care of the death 1
• Consider a debriefing meeting with the family if they desire one 1
• Provide opportunities for staff reflection through memorial rituals or debriefing sessions 1

Bereavement Support

• Formally express condolences through a card, call, or letter 1
• Refer family members to appropriate bereavement services within the institution or community 1
• Identify family members at risk for complicated bereavement or prolonged grief disorder 1

Important Clinical Pitfalls

DNR Order Limitations

• A DNR order specifically applies only to cardiopulmonary resuscitation and should not have limited other medical or surgical interventions unless explicitly specified 1, 2
• The DNR status means "do not attempt resuscitation" in the event of cardiac or pulmonary arrest, not withdrawal of all care 3

Documentation Accuracy

• Ensure the death was managed according to the DNR order without any resuscitation attempts 1
• Document that the patient's values and decisions were honored throughout the dying process 1
• Record any treatment limitations that were in place beyond the DNR order 1

Post-Mortem Procedures

• Procedures that may result in changes to cerebral and/or coronary blood flow (such as chest compressions or cardiopulmonary bypass) must not be instituted post-mortem, as these are not in the patient's interest 1
• If organ donation is proceeding, cannulation and organ perfusion should take place in the operating theatre 1