Letter to Conservator Recommending Do-Not-Resuscitate Order
Based on the patient's multiple irreversible comorbidities, massive ongoing gastrointestinal hemorrhage requiring 16 units of packed red blood cells, and exhaustion of all therapeutic options, a Do-Not-Resuscitate (DNR) order is medically appropriate and compassionate.
Dear Conservator,
I am writing to recommend a change in code status to Do-Not-Resuscitate (DNR) for your ward, who is currently hospitalized with life-threatening gastrointestinal bleeding and multiple severe chronic conditions that together make survival from cardiopulmonary arrest virtually impossible.
Current Clinical Status and Prognosis
Your ward has sustained massive gastrointestinal bleeding requiring 16 units of packed red blood cells during this admission, with hemoglobin dropping to 5.5 g/dL. 1 This degree of transfusion requirement (≥4 units) is associated with an in-hospital mortality of approximately 20% for lower gastrointestinal bleeding alone. 2
Underlying Medical Conditions
The patient carries multiple life-limiting diagnoses:
Chronic diastolic heart failure – The heart cannot adequately pump blood to meet the body's needs, particularly during the stress of resuscitation.
Stage IV chronic kidney disease – Kidney function is severely impaired. Any interventional radiology procedure with contrast dye would likely precipitate dialysis dependence, which the medical team has determined is not feasible. 2
HIV infection with CD4 count of 293 cells/µL – This indicates moderate immunosuppression and is associated with chronic inflammation, increased cardiovascular disease risk (myocardial infarction risk ratio 1.79, stroke risk ratio 2.56), and two- to ten-fold increased risk of venous thromboembolism. 3
Prior cerebrovascular accident with right-sided weakness – The patient has already suffered permanent brain damage from stroke and requires a PEG tube for nutrition.
History of ESBL infection – This indicates colonization with highly resistant bacteria, complicating any future infections.
Type 2 diabetes mellitus – Adds to cardiovascular risk and impairs wound healing.
Deep venous thrombosis with contraindication to anticoagulation – Recurrent bleeding episodes have made it impossible to safely use Eliquis (apixaban), leaving the patient at ongoing risk for life-threatening blood clots. 1
Why Therapeutic Options Are Exhausted
The medical team cannot offer the definitive treatments that would normally control gastrointestinal bleeding:
Colectomy (surgical removal of bleeding colon) cannot be performed because the patient's stage IV chronic kidney disease makes him unable to tolerate major surgery. 2
Interventional radiology angiography with embolization cannot be performed because the contrast dye required would cause acute kidney injury and force the patient into permanent dialysis. 2 While CT angiography followed by catheter embolization achieves hemostasis in 40–100% of cases and is the recommended first-line approach for unstable lower gastrointestinal bleeding, 2 this option is not available for your ward due to his renal status.
Anticoagulation for DVT cannot be safely continued due to recurrent life-threatening bleeding. 1
Without these interventions, the bleeding is likely to recur and may prove fatal. Mortality in lower gastrointestinal bleeding is generally related to underlying comorbidities rather than exsanguination, 2 and your ward has an exceptionally high burden of comorbid disease.
What Cardiopulmonary Resuscitation Would Mean
If the patient's heart were to stop (cardiac arrest), the medical team would perform chest compressions, attempt to shock the heart with electricity, insert a breathing tube, and administer powerful medications. In a patient with this constellation of severe chronic illnesses, the likelihood of surviving resuscitation to hospital discharge is extremely low—likely less than 1%. 4
Even if the heart were temporarily restarted, the underlying problems—uncontrolled bleeding, severe kidney disease, heart failure, and stroke damage—would remain. The patient would likely suffer additional injuries from resuscitation itself, including broken ribs, further brain damage from lack of oxygen, and worsening kidney failure. 5
What a DNR Order Means (and Does Not Mean)
A DNR order means that if the patient's heart stops or breathing ceases, the medical team will not perform chest compressions, electric shocks, or intubation. 6 The American Heart Association now recommends the term "Do Not Attempt Resuscitation" (DNAR) to clarify that resuscitation in this clinical context is unlikely to succeed. 6
A DNR order does NOT mean:
- Withdrawal of current medical care
- Withholding antibiotics, blood transfusions, or other supportive treatments 7
- Abandonment by the medical team
- Euthanasia or hastening death 5
Studies demonstrate that patients with DNR orders continue to receive invasive interventions including central lines, ventilator support, and dialysis at rates similar to or higher than patients without DNR orders. 7 The DNR designation applies only to the specific event of cardiopulmonary arrest.
Medical Recommendation
Given that death from recurrent bleeding or complications of multiorgan disease is highly likely and not reversible with the available medical interventions, I recommend establishing a DNR order. 4 This approach allows the medical team to continue all appropriate medical care—including blood transfusions, antibiotics, and comfort measures—while acknowledging that cardiopulmonary resuscitation would be futile and would only prolong suffering. 6
A DNR order in this context represents a compassionate recognition that some deaths cannot be prevented and that the patient's comfort and dignity should be prioritized. 4, 6
I am available to discuss this recommendation further and to answer any questions you may have about the patient's prognosis and care plan.
Sincerely,
[Physician Name]