How should disseminated intravascular coagulation (DIC) be managed in a patient with a do‑not‑resuscitate (DNR) order?

DIC Management in DNR Patients

In patients with a DNR order, DIC management should focus on treating the underlying condition and providing comfort-oriented supportive care, prioritizing symptom control over aggressive interventions that would be futile given the goals of care. 1

Core Management Principles

The fundamental approach to DIC remains treating the underlying disorder regardless of code status, as this is the cornerstone of resolving the coagulopathy. 1, 2 However, the intensity and invasiveness of interventions should align with the patient's goals of care established by the DNR order.

Underlying Condition Treatment

• Address the primary trigger (sepsis, malignancy, trauma, obstetric complications) with appropriate source control, antibiotics, or cancer-directed therapy as consistent with the patient's wishes. 1
• In cancer-associated DIC, early chemotherapy can achieve good resolution of coagulopathy, particularly in acute promyelocytic leukemia, but this should only be pursued if consistent with goals of care. 1

Symptom-Directed Supportive Care

For Active Bleeding

When bleeding causes significant distress or compromises comfort:

• Maintain platelets >50×10⁹/L if the patient is actively bleeding and transfusion aligns with comfort goals. 1, 2
• Administer fresh frozen plasma 15-30 mL/kg for prolonged PT/aPTT in patients with active bleeding causing discomfort. 1, 2
• Replace fibrinogen if <1.5 g/L persists despite FFP, using cryoprecipitate or fibrinogen concentrate. 1, 2

Critical caveat: The lifespan of transfused platelets and fibrinogen may be very short in DIC with vigorous coagulation activation, potentially requiring repeated transfusions that may not align with comfort-focused care. 3

For Thrombotic Complications

• Consider prophylactic anticoagulation with LMWH or UFH in non-bleeding patients with thrombotic-predominant DIC if this prevents symptomatic thrombosis and aligns with goals of care. 1, 2
• Avoid heparin in patients with active bleeding, platelets <20×10⁹/L, or hyperfibrinolytic DIC. 2
• In patients with high bleeding risk and renal failure, prefer unfractionated heparin over LMWH due to easier reversibility. 3

Monitoring Strategy

• Reduce monitoring intensity to what is necessary for symptom management rather than daily laboratory surveillance. 1
• Laboratory abnormalities alone should not drive transfusions in DNR patients; focus on clinical bleeding or thrombotic symptoms causing distress. 2

Treatments to Avoid

• Do not use tranexamic acid routinely, as it may increase thrombotic events and is not recommended except in therapy-resistant bleeding from hyperfibrinolytic DIC. 3
• Avoid recombinant FVIIa due to uncertain benefit and definite thrombotic risks. 3
• Do not transfuse prophylactically based on laboratory values alone without bleeding or procedures planned. 2

Key Considerations for DNR Context

The DNR order indicates a decision against cardiopulmonary resuscitation but does not automatically preclude all interventions. However, aggressive DIC management often requires:

• Repeated blood product transfusions with short-lived benefit 3
• Intensive monitoring 1
• Treatment of underlying conditions that may themselves be terminal 1

These interventions should be carefully weighed against the patient's stated goals of care, with emphasis on comfort and quality of life rather than laboratory normalization. The decision to pursue any specific intervention should involve shared decision-making with the patient or surrogate, clarifying whether the goal is comfort-focused palliation or time-limited trial of disease-modifying therapy.