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Practical guidelines for do-not-resuscitate orders

American Family Physician, Nov 1, 1994 by Mark H. Ebell

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Many approaches may be taken to initiating discussion about DNR orders, depending on the physician's individual style. It is often helpful to begin the conversation with a qualifying remark such as, "I routinely discuss CPR with my patients who are in the hospital. Do you know what CPR is?" The depiction of CPR in the mass media has resulted in significant misconceptions among patients about the length, intensity and possible outcomes of the CPR process. In order that patients give truly informed consent, it may therefore be necessary to describe the process in some detail.

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It is also important to emphasize that DNR orders are a mechanism for expressing the patient's wishes for medical care. A physician could open the discussion by saying, "I think it is important to talk about (CPR, resuscitation, endotracheal intubation) because I want to make sure that I know what kind of medical treatment you want when you are not able to talk to me or tell me your opinion." Patients may respond by putting the decision-making burden on someone else, with a statement such as "Whatever you think, doc," or "Just talk to my family." If this happens, it is important that the physician reemphasize to the patient that it is the patient's opinion that is most important, while understanding that some patients may be more comfortable with a more paternalistic model of care.

PROVIDING PROGNOSTIC INFORMATION

When discussing DNR orders with patients, it is helpful to provide concrete prognostic information. Just under one-half of patients survive the code itself, even if only for a long enough period to be transferred to the intensive care unit; one-third survive for 24 hours, and approximately one-eighth survive to hospital discharge.[8,21] In the most careful follow-up study to date, approximately 30 percent of patients who survived to discharge after CPR suffered a significant increase in dependence, requiring either extensive home care or institutionalization.[22] A smaller percentage, approximately 2 to 5 percent, have severe mental impairment.[22,23] Figure 2 shows a composite long-range survival curve, with the average patient surviving approximately three years following discharge from the hospital.

A number of diagnoses and medical conditions have been found to affect the rate of survival to discharge following CPR. These conditions are summarized in Table 2.[21] An especially poor prognosis is associated with metastatic cancer, sepsis, dependent functional status and elevated serum creatinine level.

Two predictive scores have been proposed that use a combination of these variables to identify patients who will not survive to discharge if resuscitation is attempted.[21,24] Success in applying these scores to independent populations has been mixed, and more work is needed to validate these scores before they can be used in clinical practice.[25-27]

INVOLVING OTHERS IN THE DECISION-MAKING PROCESS

If a conflict exists, or if a patient indicates a desire to discuss issues regarding resuscitation with family members, a family meeting may be an appropriate forum for discussion. Although most patients place the greatest value on the input of their spouse, physician and children, it is best to ask the patient exactly who should attend a discussion about DNR orders. It may be appropriate in some instances to include lovers, life companions, ministers, social workers and nursing staff.[13]

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Practical guidelines for do-not-resuscitate orders

American Family Physician, Nov 1, 1994 by Mark H. Ebell

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