Letter to Conservator Recommending Code Status Change to DNR
I recommend that the conservator consent to changing this patient's code status from Full Code to Do-Not-Resuscitate (DNR) with Comfort Measures Only, given the patient's metastatic pancreatic adenocarcinoma, multiple severe comorbidities, advanced dementia, and life expectancy measured in months.
Clinical Rationale for DNR Recommendation
Poor Prognosis and Limited Life Expectancy
This patient meets multiple criteria requiring immediate palliative care consultation and code status reassessment, including metastatic pancreatic cancer, life expectancy less than 6 months, severe dementia affecting decision-making capacity, and progressive functional decline 1.
Metastatic pancreatic adenocarcinoma has an extremely poor prognosis even with chemotherapy, with gemcitabine providing modest clinical benefit primarily for symptom palliation rather than meaningful survival extension 1, 2, 3.
The combination of metastatic cancer, advanced heart failure, COPD, and severe dementia creates a clinical scenario where CPR survival rates would be less than 1-5%, with survivors experiencing significant additional functional decline 4, 5.
Futility of Cardiopulmonary Resuscitation
Patients with multiple comorbidities including metastatic cancer, heart failure, and COPD who undergo CPR have survival rates below 5%, and often below 1%, with the majority of survivors experiencing severe neurological impairment and further functional deterioration 4, 5.
The patient's severe dementia already represents significant cognitive impairment, and CPR would likely result in additional hypoxic brain injury, prolonged mechanical ventilation that conflicts with the underlying COPD and heart failure, and increased suffering without meaningful recovery 4, 5.
Cardiopulmonary arrest in this clinical context would represent the natural progression of multiple end-stage disease processes rather than a reversible acute event 1.
Recommended POLST Orders
Section A: Cardiopulmonary Resuscitation
- Do Not Attempt Resuscitation (DNAR/DNR) - No chest compressions, no defibrillation, allow natural death 1, 4.
Section B: Medical Interventions
- Comfort Measures Only - This approach includes 1:
- Medications by any route for pain and symptom relief (continue morphine)
- Oxygen and suction for comfort (continue supplemental oxygen)
- Positioning and wound care
- No transfer to hospital for life-sustaining treatment
- Transfer only if comfort needs cannot be met in current location
Alignment with Palliative Care Guidelines
Immediate Palliative Care Focus
The National Comprehensive Cancer Network strongly recommends that patients with metastatic pancreatic cancer receive comprehensive palliative care assessment at first visit, with formal palliative care consultation indicated for those with life expectancy less than 6 months 1.
When life expectancy is measured in weeks to months, guidelines recommend discontinuing disease-directed therapy, intensifying palliative care in preparation for death, focusing exclusively on symptom control and comfort, and referring to hospice services 1.
The patient's current palliative chemotherapy with gemcitabine should be reassessed, as guidelines indicate that when life expectancy is months or less, the focus should shift entirely to comfort rather than continuing treatments that may increase suffering without meaningful benefit 1, 6.
Symptom Management Priorities
Continue aggressive pain management with morphine, with dose adjustments as needed for comfort 1.
Maintain supplemental oxygen for dyspnea relief, using the lowest flow that provides subjective comfort 1.
Consider adding benzodiazepines (such as lorazepam 0.5-1 mg as needed) if the patient experiences anxiety or air hunger despite oxygen 1.
Optimize diuretic therapy for heart failure symptoms, potentially transitioning to subcutaneous administration if oral intake becomes difficult 1.
Legal and Ethical Framework
Substituted Judgment Standard
As conservator, you are legally obligated to make decisions based on what the patient would have chosen if they had decision-making capacity, considering their previously expressed values, beliefs, and preferences 1, 5.
The principle of substituted judgment requires placing the patient's own preferences at the center of deliberation, seeking to preserve their right of self-determination even when they cannot currently express those preferences 1.
Given the patient's severe dementia, you should consider any previously expressed wishes about end-of-life care, religious or cultural beliefs about death and dying, and their general approach to medical interventions throughout their life 1.
Capacity and Decision-Making
The patient's severe dementia indicates lack of decision-making capacity, which requires assessment of their ability to understand their medical condition, comprehend the consequences of treatment decisions, weigh choices, and commit to a decision 1.
Advance care planning for patients lacking capacity requires appropriate surrogate involvement (the conservator in this case) to ensure decisions align with the patient's values and goals 1, 5.
Communication Framework for This Discussion
Essential Information to Convey
The patient has multiple end-stage diseases that are progressing despite treatment, with death expected within months regardless of interventions 1.
CPR in this clinical context would involve violent chest compressions likely causing rib fractures, mechanical ventilation requiring sedation and restraints, and intensive care interventions, with survival probability below 1-5% and high likelihood of additional neurological damage 4, 5.
"Doing everything" in this situation means ensuring the patient is comfortable, pain-free, and treated with dignity, rather than subjecting them to aggressive interventions that would increase suffering without providing benefit 4, 5.
Goals of Care Redirection
The appropriate goal at this stage is maintaining quality of life, ensuring comfort, relieving suffering, and allowing natural death when it occurs 1, 6.
This approach honors the patient's dignity and focuses on what can be achieved—excellent symptom control, peaceful environment, and support for family—rather than futile attempts to reverse irreversible disease processes 1.
Recommended Next Steps
Immediate Actions
Complete POLST form with DNR and Comfort Measures Only selections, ensuring the bright-colored form is visible in the medical chart and accompanies the patient across all care settings 1, 4, 5.
Arrange formal palliative care or hospice consultation within 48-72 hours to optimize symptom management and provide additional support 1.
Communicate the code status change to all healthcare providers involved in the patient's care, including primary care physician, oncologist, cardiologist, and nursing staff 1, 5.
Hospice Evaluation
Given life expectancy of months, the patient meets hospice eligibility criteria and should be evaluated for hospice services, which provide more intensive symptom management, family support, and bereavement services 1, 6.
Hospice care is associated with better symptom control, reduced aggressive interventions at end of life, and improved family bereavement outcomes 6, 5.
Ongoing Care Plan
Continue morphine for pain with dose titration as needed for comfort 1.
Maintain supplemental oxygen at the lowest flow providing subjective relief 1.
Reassess the benefit of continuing gemcitabine chemotherapy, as guidelines recommend discontinuing disease-directed therapy when life expectancy is months and focusing exclusively on comfort 1, 6.
Provide anticipatory guidance to family about the expected dying process, including decreased oral intake, increased sleeping, and changes in breathing patterns 1.
Critical Pitfalls to Avoid
Do not interpret DNR as "do not treat"—the patient should continue receiving aggressive symptom management, nursing care, and all comfort-promoting interventions 1.
Avoid delaying this decision until a crisis occurs, as emergency situations create additional distress for family and often result in unwanted aggressive interventions 1, 5.
Do not continue chemotherapy simply because it was previously started—when life expectancy is months, continuing treatments that cause side effects without meaningful benefit increases suffering 1, 6.
Ensure the POLST form is bright-colored, easily visible, and transferred with the patient to any care setting, as emergency personnel are legally required to honor these orders 1, 4, 5.