In a competent 50‑year‑old woman with severe multiple sclerosis, end‑stage renal disease, and a Do‑Not‑Resuscitate order who now has life‑threatening hyperkalemia, should urgent dialysis be provided while respecting the DNR?

DNR Does Not Preclude Dialysis for Life-Threatening Hyperkalemia

A Do-Not-Resuscitate order applies narrowly to cardiopulmonary resuscitation only and does not restrict other life-sustaining treatments including urgent dialysis for severe hyperkalemia. The appropriate action is to proceed with dialysis (Option A is misleading—no "reversal" of DNR is needed; dialysis is already permitted under DNR status).

Understanding DNR Scope and Limitations

DNR orders are procedure-specific and apply solely to cardiopulmonary resuscitation in the event of cardiac or pulmonary arrest 1. The American Heart Association explicitly states that DNR or DNI status does not limit the use of other treatments such as vasopressors, oxygen support, or electrolyte replacement 1.

• A DNR order should apply narrowly to its stated purpose and not affect other aspects of medical care 1
• Studies demonstrate that DNR orders are often inappropriately interpreted to mean "do not treat," leading to less aggressive care beyond resuscitation efforts 1
• The decision to limit specific medical or surgical treatments should be part of separate shared decision-making discussions between surrogates and physicians 1

Clinical Urgency of Severe Hyperkalemia

This patient has life-threatening hyperkalemia (K+ = 6.0 mEq/L) requiring immediate intervention 2. The American Heart Association defines severe hyperkalemia as potassium ≥6.5 mEq/L, but this patient's level of 6.0 mEq/L falls into the moderate-to-severe range requiring urgent treatment 2.

Immediate Treatment Algorithm for Hyperkalemia

1. Cardiac membrane stabilization: Administer IV calcium (calcium chloride 10%: 5-10 mL or calcium gluconate 10%: 15-30 mL over 2-5 minutes) to protect against arrhythmias 2

2. Shift potassium into cells:

   • Insulin 10 units IV with 25g glucose (D50W 50 mL) over 15-30 minutes 2
   • Nebulized albuterol 10-20 mg over 15 minutes 2
   • Sodium bicarbonate 50 mEq IV over 5 minutes if metabolic acidosis present 2

3. Eliminate potassium from body:

   • Hemodialysis is the most effective method for severe hyperkalemia, especially in ESRD patients 2
   • Loop diuretics (furosemide 40-80 mg IV) only effective with adequate renal function 2
   • Newer potassium binders (patiromer, sodium zirconium cyclosilicate) for ongoing management 2

Dialysis in ESRD with DNR Status

For patients with ESRD and severe hyperkalemia, dialysis is a standard medical treatment—not a resuscitative measure—and is fully compatible with DNR status 1. The American Heart Association notes that continuous renal replacement therapy (CRRT) is favored over intermittent dialysis in hemodynamically unstable patients 1.

• ESRD patients requiring dialysis have higher mortality risk, but dialysis remains appropriate when consistent with patient goals 1
• The decision to initiate or continue dialysis should be based on patient-centered goals, quality of life considerations, and prognosis 1
• Discontinuation of dialysis is a separate decision from DNR status and requires its own shared decision-making process 1

Patient Autonomy and Competent Decision-Making

This alert, competent 50-year-old patient has the right to make her own medical decisions 1, 3. The DNR order she requested specifically addresses resuscitation preferences, not all medical care.

• Documentation shows that historically only 14% of patients but 77% of families are consulted about DNR orders, highlighting the importance of direct patient involvement when possible 4
• Family consent (Option D) is not required when the patient is competent and alert 4
• The patient's autonomy must be respected, but this includes respecting her choice for DNR while still providing appropriate medical treatment 3

Critical Distinction: Treatment vs. Resuscitation

"Do Not Resuscitate" does not mean "Do Not Treat" 3. This fundamental principle is often misunderstood in clinical practice.

• Studies show that DNR orders inappropriately lead to less aggressive care including lower likelihood of admission to specialized units, fewer surgical procedures, and less guideline-concordant care 1
• Dialysis for hyperkalemia is a medical treatment to correct a life-threatening electrolyte abnormality, not a resuscitative measure 1
• The patient's DNR status should not prevent treatment of reversible, acute conditions like hyperkalemia 1, 3

Shared Decision-Making Approach

The appropriate clinical approach involves discussing treatment options with this competent patient 1:

1. Explain that her DNR order remains in effect and will be honored
2. Clarify that dialysis is a separate medical treatment for her hyperkalemia and kidney failure
3. Discuss the risks, benefits, and alternatives to dialysis
4. Explore her goals of care and quality of life priorities
5. Document her informed decision regarding dialysis

The European Society of Cardiology emphasizes that open and sensitive communication with patients allows advanced planning and discussion about their fears, concerns, and wishes 1. For patients with ESRD, consensual avoidance or discontinuation of dialysis can become alternatives when consistent with patient-centered goals 1.

Common Pitfalls to Avoid

• Never assume DNR means withholding all aggressive treatments 1, 3
• Do not seek family consent when the patient is competent 4
• Avoid conflating resuscitation preferences with treatment preferences 1, 3
• Do not delay urgent treatment of life-threatening conditions like severe hyperkalemia 2, 5
• Recognize that early care limitations can create self-fulfilling prophecies of poor outcomes 1

In summary: Proceed with dialysis while maintaining the DNR order. The patient's competent DNR request addresses only cardiopulmonary resuscitation, not medical treatments like dialysis for life-threatening hyperkalemia in the setting of ESRD.