In a patient with advanced lung cancer and end‑stage respiratory failure who has documented DNR wishes but whose family desires aggressive treatment, what should the care team prioritize first?

Prioritize Documented Patient DNR Preference

The care team must prioritize the patient's documented DNR wishes over family preferences, as patient autonomy and advance directives take precedence in end-of-life decision-making. 1

Legal and Ethical Framework

The DNR order is a legal directive that must be respected when properly documented, representing the patient's autonomous decision about their own medical care 1. The European Society for Medical Oncology explicitly states that DNR requests are made by the patient and allow the medical team to respect the patient's wishes, not the family's desires 1.

Key Principles for This Case

• Patient autonomy supersedes family wishes when the patient has documented their preferences while having decision-making capacity 1
• The documented DNR order should be implemented and compliance ensured, particularly for patients with weeks-to-days life expectancy 1
• When families disagree with documented patient wishes, the team should seek conflict resolution through ethics consultation, social work, or chaplaincy services—but the patient's documented preference remains the guiding principle 1

Addressing Team Uncertainty

The phrase "team uncertain about the true wishes of the patient" requires immediate clarification through the following steps:

1. Verify Documentation Quality

• Review the DNR documentation for completeness: Was it signed by the patient? Was capacity assessed at the time? Is it current and valid? 2
• Confirm the DNR order specifies which interventions are withheld (CPR, intubation, mechanical ventilation) 2
• Ensure the documentation includes the date of implementation and patient's capacity at time of decision 2

2. Explore the Source of Uncertainty

• If uncertainty stems from recent changes in patient condition: The American Heart Association guidelines note that DNR discussions should occur before crisis situations, and documented preferences should guide care unless the patient explicitly revokes them 1
• If uncertainty stems from family pressure: The NCCN guidelines explicitly state that when patient, family, and professional team disagree on benefit/utility of interventions, ethics consultation should assist in conflict resolution—but this does not override valid patient directives 1
• If uncertainty stems from inadequate prior documentation: This represents a systems failure, but the team should not default to CPR simply due to poor documentation 3

Critical Pitfalls to Avoid

• Never assume family wishes override documented patient preferences 1
• Do not initiate CPR "to buy time" for family discussions when a valid DNR exists—this violates the patient's autonomy and documented wishes 1, 4
• Avoid misinterpreting DNR as "do nothing"—DNR only restricts CPR and intubation, not aggressive symptom management, antibiotics, or other comfort measures 1, 4
• Do not delay implementing the DNR while seeking family agreement—the patient's documented preference is legally and ethically binding 1

Recommended Action Algorithm

Immediate Steps (Within Hours)

1. Retrieve and review all advance care planning documentation to confirm the DNR order's validity, specificity, and currency 1, 2
2. Convene a family meeting with palliative care consultation to explain that the patient's documented wishes must be honored, while addressing family concerns about prognosis and goals of care 1
3. Clarify what treatments will continue: Emphasize that DNR does not mean withdrawal of all care—symptom management, oxygen, antibiotics, and comfort measures continue 1, 4

If Documentation is Ambiguous

• Obtain ethics consultation immediately to review the case and provide guidance 1
• In the interim, continue current supportive care but do not escalate to CPR or intubation given the patient's advanced disease and end-stage status 1
• Document all discussions thoroughly, including the team's uncertainty, family perspectives, and clinical reasoning 2

Managing Family Conflict

The NCCN guidelines acknowledge that families may not agree with patient preferences, but this does not change the ethical obligation to honor documented patient wishes 1. The American Society of Clinical Oncology reinforces that oncologists should feel no obligation to provide interventions that clinical evidence suggests will provide no meaningful benefit, particularly when contrary to documented patient preferences 1.

Communication Strategy

• Explain that respecting the patient's DNR honors their autonomy and dignity 1
• Acknowledge the family's distress while clarifying that the medical team's legal and ethical duty is to the patient's documented wishes 1
• Offer intensive palliative care support to both patient and family, emphasizing what will be done (comfort, symptom control, presence) rather than what won't be done 1, 4
• Consider involving chaplaincy or bereavement services to support the family through this difficult time 1

Special Considerations for This Clinical Context

In a patient with advanced lung cancer and end-stage respiratory failure experiencing an acute exacerbation, the likelihood of meaningful recovery from cardiac arrest is extremely low 1. The American Heart Association explicitly notes that DNAR orders should be considered "based on patient or family preference as well as expectation of outcome, taking into account the clinical judgment of experienced providers" 1. However, when documented patient preference exists, it takes precedence over family preference 1.

The answer is D: documented patient preference regarding DNR must be prioritized first.