What is the best management approach for a patient with end-stage cancer, metastases to the femur and backbone, and a DNR (do not resuscitate) order?

Management of End-Stage Cancer with DNR Order: Focus on Comfort Care

The correct answer is C) Morphine – for a patient with end-stage cancer, metastatic bone disease, and a DNR order, the priority is symptom management and comfort care, with opioids like morphine being the cornerstone of palliative treatment. 1

Understanding DNR in the Context of End-Stage Cancer

A DNR order specifically means that cardiopulmonary resuscitation and advanced cardiac life support will not be initiated if the heart or breathing stops. Critically, a DNR order does not preclude access to any appropriate treatment such as supportive or palliative care – it only restricts CPR and intubation. 1

The European Society for Medical Oncology emphasizes that "allow natural death" (AND) is the preferred terminology in far advanced cancer, as it presents palliation rather than CPR as the normative default. 1

Why Morphine is the Appropriate Choice

Pain Management in Bone Metastases

• Patients with metastatic disease to the femur and backbone typically experience significant pain that requires aggressive symptom management. 1
• Opioid analgesics are the foundation of pain control in this setting, particularly when combined with other modalities. 1
• The goal shifts from life-prolonging interventions to maintaining quality of life and comfort. 1

What DNR Does NOT Restrict

A DNR order does not affect treatments other than those requiring intubation or CPR, meaning all comfort measures, medications for symptom control, and supportive care remain fully appropriate. 1

Why Options A and B are Inappropriate

Inotropic Support (Option A)

• Inotropic agents are life-sustaining cardiovascular interventions aimed at prolonging life in acute cardiac failure. 2
• These represent aggressive, life-prolonging measures inconsistent with the goals of care in end-stage cancer with DNR status. 2
• DNR orders specifically indicate that the patient does not want escalation to intensive life-sustaining interventions. 2

Mechanical Ventilation (Option B)

• Mechanical ventilation requires intubation, which is explicitly contraindicated by DNR orders. 1, 2
• DNR orders instruct healthcare providers not to perform interventions like endotracheal intubation and mechanical ventilation. 2
• This would directly violate the patient's documented wishes. 1

Why "Don't Give Medication" (Option D) is Wrong

This represents a fundamental misunderstanding of DNR orders and palliative care principles. 1

• DNR does not mean "do not treat" – it means do not perform CPR/intubation. 1
• Reasonable and proper care, including all appropriate treatments not specifically refused, should be continued. 2
• Withholding symptom management medications would constitute abandonment and cause unnecessary suffering. 1
• Palliative medications like morphine are essential to maintain comfort and dignity. 1, 2

Comprehensive Palliative Approach for Bone Metastases

While morphine is the priority answer, optimal management of bone metastases in this setting includes:

Multimodal Pain Control

• External beam radiation therapy provides pain relief in bone metastases (though a single 8 Gy fraction is effective and cost-effective). 1
• Bisphosphonates (like zoledronic acid) reduce skeletal-related events and provide additional pain control. 1
• These adjunctive therapies complement, but do not replace, opioid analgesia. 1

Surgical Considerations

• Prophylactic surgical fixation may be considered for impending pathologic fractures in weight-bearing bones when survival expectancy exceeds 4 weeks and the patient has satisfactory health status. 1
• However, in end-stage disease with DNR status, the risk-benefit ratio typically favors conservative management with aggressive symptom control. 1

Common Pitfalls to Avoid

1. Misinterpreting DNR as "do nothing" – DNR only restricts CPR and intubation, not comfort care. 1, 2

2. Delaying opioid initiation – Pain control should be aggressive and immediate in metastatic bone disease. 1

3. Pursuing life-prolonging interventions – Inotropes and mechanical ventilation contradict the goals of care established by DNR. 2

4. Inadequate documentation – Ensure the DNR order clearly specifies which interventions are withheld while confirming continued comfort measures. 2