DNR and Gastrostomy in Neonatal Hypoxic Encephalopathy
A DNR order does not preclude gastrostomy placement, and the DNR should remain in place while proceeding with the gastrostomy for nutritional support.
Understanding DNR Scope in Neonatal Care
The critical distinction is that DNR orders specifically address cardiopulmonary resuscitation only and do not automatically limit other medical interventions. 1
- A DNR order does not preclude interventions such as parenteral fluids, nutrition, oxygen, analgesia, sedation, or surgical procedures unless these are explicitly included in the order 1
- The scope of a DNR order should specify which interventions are to be withheld, and all other care should be administered without delay 1
- DNR orders carry no implications about other forms of treatment, and other aspects of the treatment plan should be documented separately 1
Gastrostomy as Supportive Care
Gastrostomy placement is a supportive nutritional intervention, not a resuscitative measure, and falls outside the scope of a standard DNR order. 1
- Nutritional support through gastrostomy improves quality of life by preventing malnutrition and aspiration risk in infants with oral motor dysfunction from HIE 2
- Infants with HIE frequently require prolonged time to achieve full oral feeds, with severity of encephalopathy predicting feeding difficulties 2
- Early enteral nutrition in HIE patients undergoing therapeutic hypothermia has been shown to be safe and may shorten hospital stay 3
Perioperative DNR Management
DNR orders should be reviewed before surgery by the anesthesiologist, attending surgeon, and surrogate to determine their applicability during the procedure and immediate postoperative period. 1
- This review does not require revoking the DNR permanently, but rather clarifying its application during the surgical period 1
- The discussion should address specific emergency interventions that may arise during surgery, including use of vasopressors, mechanical ventilation, blood products, or antibiotics 1
- After the perioperative period, the original DNR order typically remains in effect unless modified through discussion with the family 1
Clinical Context for This Case
In a term infant with HIE who has survived the acute phase and requires gastrostomy, the DNR reflects goals of care focused on comfort and avoiding futile resuscitation, not withdrawal of all supportive measures. 1
- Approximately 6.8% of patients with anoxic/hypoxic ischemic encephalopathy require gastrostomy tube placement 4
- Brainstem injury on MRI is most highly associated with need for gastrostomy tube, though overall incidence remains relatively low at 5% in HIE populations 2
- Gastrostomy placement allows for safe nutrition delivery and may facilitate discharge to home or long-term care facility 5, 2
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 supportive care 1
- Do not automatically revoke DNR for all surgical procedures - instead, have a specific discussion about the perioperative period and what interventions are acceptable 1
- Do not confuse resuscitative measures with supportive care - gastrostomy is nutritional support that improves quality of life, not life-prolonging resuscitation 1
The correct answer is that the DNR should remain in place (with perioperative clarification as needed) and gastrostomy should be allowed, as these are not mutually exclusive decisions.