How should a Do Not Resuscitate (DNR) order be discussed for a critically ill patient in the Intensive Care Unit (ICU)?

DNR Orders Must Be Discussed With the Patient or Their Family

DNR orders should be discussed with the patient if they have decisional capacity, or with the patient's family/surrogate decision-maker if the patient lacks capacity—this is a fundamental ethical and legal requirement for valid DNR orders. 1

The Correct Answer and Why

Option B (discussed with the patient) and Option C (discussed with the patient's family) are both correct, depending on the patient's capacity. Options A and D are incorrect—DNR orders do not require three physicians nor hospital administrators for decision-making. 1

Decision-Making Framework for DNR Orders

Step 1: Assess Patient Capacity

• If the patient has decisional capacity: The patient has the right to give or withhold consent for a DNR order and must be directly involved in the discussion. 1, 2
• If the patient lacks capacity: Family members or legally appointed surrogate decision-makers must be engaged as sources of information about patient preferences and values, and may legally act as surrogate decision-makers. 1

Step 2: Timing of DNR Discussions

• Avoid early DNR orders in the first 24-48 hours unless the patient has pre-existing advance directives, as early care limitations become self-fulfilling prophecies of poor outcome due to inaccurately pessimistic prognostication. 3
• Provide aggressive full care early after ICU admission, and postpone new DNR orders until at least the second full day of hospitalization for most critically ill patients. 3
• DNR discussions are appropriate when the patient has advanced age or terminal condition, when CPR would not prevent impending death, when intervention cannot accomplish physiological goals (futile), or when transitioning to comfort-focused care. 3

Step 3: Communication Requirements

• Start by eliciting the patient's/surrogate's understanding of the medical situation rather than delivering an "opening monologue." 1
• Use the "Ask-Tell-Ask" approach: Ask permission to discuss prognosis, convey prognostic information, then assess understanding. 1
• Explain key prognostic domains including risks of short and long-term mortality, ventilator dependence, functional impairment, and cognitive impairment. 1
• Highlight that there is a choice among several reasonable treatment pathways including full life support, time-limited trial of ICU care, and purely palliative approach. 1

Step 4: Explain Surrogate Decision-Making Principles

• Clarify the surrogate's role: Most ICU decisions are value-laden and require the surrogate's input to personalize care to the patient's values, goals, and preferences. 1
• The ethical goal: Enact the patient's previously stated treatment preferences if applicable and contemporary, not the surrogate's own preferences. 1
• Assess preferred level of involvement: Surrogates differ in their ability and willingness to share decisions and should be asked about their preferred level of involvement. 1

Essential Documentation Requirements

All DNR orders must include written documentation (oral DNR orders are never acceptable) with the following components: 3, 4

• Clear statement of patient's capacity at time of decision-making
• Date of DNR order implementation
• Specific interventions to be withheld
• Interventions that remain permitted
• Record of discussion with patient and/or surrogate decision-maker, including patient's values, goals, and preferences
• Rationale for the DNR order

Critical Distinctions About DNR Status

DNR status does not limit other treatments and should not result in withdrawal of appropriate medical care: 3, 4

• Vasopressors can still be administered
• Oxygen support continues
• Electrolyte replacement is appropriate
• IV fluids, pain management, and antibiotics remain indicated

Common Pitfalls to Avoid

• Self-fulfilling prophecies: Early DNR orders lead to less aggressive care, which results in the predicted poor outcome. 3
• Inadequate family understanding: Meaningful discussions require that families have good understanding of life-sustaining treatments, level and intensity of support provided, and the patient's resuscitation status. 1
• Failure to assess coping strategies: ICU staff must identify coping strategies used by each patient and/or family member to provide optimal communication and personalized goals of care discussions. 1
• Assuming surrogates refuse to discuss prognosis: If surrogates refuse, educate them about why this information is critical; if refusal persists, identify an alternate surrogate or seek ethics consultation. 1
• Inadequate prognostication discussion documentation: Document the actual discussion of prognosis, not just the prognosis itself. 3

Role of Healthcare Team Members

Support persons can facilitate difficult conversations: Nurses, patient advocates, social workers, and clergy members may help mediate disputes and assist families during DNR discussions. 2, 5

Ethics consultation should be obtained when conflicts arise between healthcare providers and patients/families regarding DNR decisions, employing basic principles of negotiation and conflict resolution. 4, 2