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 is both B and C, depending on the patient's capacity to participate in decision-making.
Decision-Making Framework Based on 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
- Even critically ill patients should be asked for their input whenever feasible, rather than assuming they are too confused or sedated to contribute. 2
- The patient's values, goals, and preferences must be elicited directly from them when possible. 2
If the Patient Lacks Decisional Capacity
- Family members or legally appointed surrogate decision-makers must be engaged as sources of information about patient preferences and values. 1
- Surrogates may legally act as decision-makers in the absence of the patient's capacity. 1
- The ethical goal is to enact the patient's previously stated treatment preferences if applicable, not the surrogate's own preferences. 1
The Shared Decision-Making Process
The American College of Critical Care Medicine and American Thoracic Society recommend a default approach involving three key stages 2:
1. Information Exchange
- Clinicians share information about treatment options, risks, and benefits. 2
- The patient/surrogate shares information about the patient's values, goals, and preferences. 2
- Most surrogates prefer to share the authority and burden of decision-making with clinicians rather than making decisions independently. 2
2. Deliberation
- Both clinicians and patient/surrogate engage in back-and-forth discussions about the pros and cons of various options. 2
- Clinicians should use the "Ask-Tell-Ask" approach: ask permission to discuss prognosis, convey prognostic information, then assess understanding. 1
- Start by eliciting the patient's/surrogate's understanding rather than delivering an "opening monologue." 1
3. Reaching Agreement
- Clinicians and patients/surrogates agree on the decision to implement. 2
- The clinician should generally offer a recommendation based on both medical facts and the patient's values. 2
Why the Other Options Are Incorrect
Option A: "3 Worthy Doctors"
- There is no requirement for multiple physicians to authorize a DNR order. The attending physician should facilitate these discussions. 2
- The decision is based on shared decision-making between clinicians and patient/family, not a committee of doctors. 2
Option D: Hospital Administrators
- Hospital administrators are not involved in DNR discussions. [2-1]
- DNR decisions are clinical and ethical matters between the medical team and patient/family, not administrative decisions. 1
Common Pitfalls to Avoid
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 due to inaccurately pessimistic prognostication. 1
- Discussions about goals of care should be started early, but new DNR orders should generally be postponed until at least the second full day of hospitalization for most critically ill patients. 1
Communication Failures
- Inadequate family understanding can occur if families don't fully grasp life-sustaining treatments and resuscitation status. 1
- Ensure families understand the medical situation, prognosis, and what DNR means (and doesn't mean) for ongoing care. 1
- DNR status does not limit other treatments—vasopressors, oxygen support, antibiotics, pain management, and other appropriate medical care continue. 1