A 50-year-old female with severe multiple sclerosis and newly diagnosed end-stage renal disease who is alert and has a Do-Not-Resuscitate order now has hyperkalemia; what is the appropriate action?

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Management of Hyperkalemia in an Alert ESRD Patient with DNR Status

The appropriate action is to treat the hyperkalemia with standard medical management (kayexalate or newer potassium binders) and discuss goals of care with the patient directly—not the family—while respecting the DNR order, which does not preclude dialysis or other life-sustaining treatments. 1, 2

Understanding DNR vs. Treatment Limitations

A DNR order specifically addresses cardiopulmonary resuscitation in the event of cardiac or respiratory arrest—it does NOT automatically prohibit dialysis, medications, or other medical interventions. 1 The patient is alert and has decision-making capacity, so all treatment discussions must occur directly with her, not with family members unless she designates them as her healthcare proxy. 1

  • Dialysis is NOT contraindicated by a DNR order. The decision to pursue or decline dialysis is separate from resuscitation preferences and must be discussed with the patient based on her goals of care, quality of life, and understanding of ESRD management. 1, 2
  • Treating hyperkalemia with medications (kayexalate, newer potassium binders, insulin/glucose, calcium) is standard care and does not violate a DNR order. 1, 2, 3

Immediate Management of Hyperkalemia (K⁺ = 6.0 mEq/L)

Step 1: Obtain an ECG Immediately

  • Check for peaked T waves, widened QRS, prolonged PR interval, or arrhythmias. If any ECG changes are present, this constitutes a medical emergency requiring immediate treatment regardless of the exact potassium level. 2, 3
  • If ECG changes are present, administer IV calcium gluconate 10% (15–30 mL over 2–5 minutes) immediately to stabilize the cardiac membrane while other therapies take effect. Calcium does NOT lower potassium—it only protects the heart temporarily (30–60 minutes). 2, 4, 3

Step 2: Shift Potassium Intracellularly (if ECG changes or symptomatic)

  • Insulin 10 units IV with 25 grams dextrose (D50W 50 mL) lowers potassium by 0.5–1.2 mEq/L within 30–60 minutes, lasting 4–6 hours. 2, 5, 3
  • Nebulized albuterol 10–20 mg in 4 mL over 10 minutes can augment the insulin effect, lowering potassium by an additional 0.5–1.0 mEq/L. 2, 3
  • Sodium bicarbonate 50 mEq IV over 5 minutes ONLY if metabolic acidosis is present (pH < 7.35, bicarbonate < 22 mEq/L). Do not use bicarbonate without documented acidosis—it is ineffective and wastes time. 2, 6, 3

Step 3: Remove Potassium from the Body

  • Kayexalate (sodium polystyrene sulfonate) 15–30 grams orally or 30–50 grams rectally can be used to increase fecal potassium excretion, though onset is slow (hours to days) and efficacy is limited. 5, 3, 7

    • Avoid kayexalate with sorbitol in patients with recent abdominal surgery, bowel injury, or intestinal dysfunction due to risk of colonic necrosis (0.2–0.3% incidence). 7
    • Newer potassium binders (patiromer or sodium zirconium cyclosilicate) are safer and more effective for chronic hyperkalemia management but have slower onset (1–7 hours). 2, 5, 3

  • Hemodialysis is the most effective method for severe hyperkalemia (K⁺ > 6.5 mEq/L, ECG changes unresponsive to medical therapy, oliguria, or ongoing potassium release). 2, 8, 3 However, dialysis initiation in ESRD is a separate decision from DNR status and requires a goals-of-care discussion with the patient. 1, 2

Goals-of-Care Discussion with the Patient

Because the patient is alert and has decision-making capacity, you must discuss treatment options directly with her—not with the family—unless she has designated a healthcare proxy. 1

Key Points to Address:

  1. Explain that DNR does NOT mean "do not treat." It only applies to CPR in the event of cardiac arrest. 1
  2. Discuss the role of dialysis in ESRD: Without dialysis, hyperkalemia will recur and may lead to fatal arrhythmias. Dialysis is the definitive treatment for ESRD-related hyperkalemia. 2, 8, 3
  3. Explore her goals: Does she want life-sustaining treatments like dialysis, or does she prefer comfort-focused care? If she declines dialysis, discuss palliative care options. 1
  4. Clarify that treating hyperkalemia with medications (kayexalate, insulin, calcium) is standard care and does not conflict with her DNR order. 1, 2, 3

Why the Other Options Are Incorrect

Option A: "Dialysis is possible after reversal of DNR"

  • This is incorrect. DNR orders do not need to be "reversed" to perform dialysis. DNR only applies to CPR during cardiac arrest—it does not prohibit dialysis or other treatments. 1, 2

Option B: "Dialysis cannot be done because of DNR"

  • This is incorrect. DNR does not preclude dialysis. The decision to pursue or decline dialysis is separate from resuscitation preferences and must be discussed with the patient. 1, 2

Option C: "Ignore the patient's wishes and proceed with dialysis"

  • This is incorrect and unethical. The patient has decision-making capacity and must be involved in all treatment decisions. Ignoring her autonomy violates medical ethics and informed consent principles. 1

Option D: "Give kayexalate and discuss DNR with the family"

  • This is partially correct but incomplete. Kayexalate is appropriate for treating hyperkalemia, but the discussion must occur with the patient, not the family, unless she has designated a healthcare proxy. 1, 3, 7

Common Pitfalls to Avoid

  • Do not assume DNR means "do not treat." DNR only applies to CPR during cardiac arrest—it does not prohibit dialysis, medications, or other interventions. 1, 2
  • Do not delay treatment while waiting for repeat potassium levels if ECG changes are present. ECG abnormalities indicate urgent need for calcium and potassium-lowering therapies. 2, 3
  • Do not use sodium bicarbonate without documented metabolic acidosis. It is ineffective without acidosis and wastes time. 2, 6, 3
  • Do not discuss treatment decisions with the family instead of the patient unless she has designated a healthcare proxy. The patient is alert and has decision-making capacity. 1

Summary Algorithm

  1. Obtain ECG immediately. If ECG changes are present, give IV calcium gluconate 10% (15–30 mL over 2–5 minutes). 2, 4, 3
  2. Shift potassium intracellularly: Insulin 10 units IV + 25 grams dextrose, nebulized albuterol 10–20 mg. 2, 5, 3
  3. Remove potassium: Kayexalate 15–30 grams orally or newer potassium binders (patiromer, sodium zirconium cyclosilicate). 5, 3, 7
  4. Discuss goals of care directly with the patient: Clarify that DNR does not preclude dialysis or other treatments. Explore her preferences for life-sustaining therapies. 1, 2
  5. If she declines dialysis, initiate palliative care and manage hyperkalemia symptomatically with medications. 1, 3

References

1
Guideline

Potassium Supplementation for Hypokalemia

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Hyperkalemia Management Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Research

Potassium Disorders: Hypokalemia and Hyperkalemia.

American family physician, 2023

6
Research

Treatment of Severe Hyperkalemia: Confronting 4 Fallacies.

Kidney international reports, 2018

7
Research

Damned if you do, damned if you don't: potassium binding resins in hyperkalemia.

Clinical journal of the American Society of Nephrology : CJASN, 2010

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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