Important Considerations for DNAR Orders

00:01 There are important considerations when thinking about DNAR orders.

00:05 So, the first is that it only applies to resuscitative interventions. It's only with regard to CPR.

00:14 It should not mean it speaks to other aspects of the patient's care.

00:18 So, any other decisions about their goals of care really need to be framed for those particular decisions.

00:26 So, whether there's antibiotics, whether they're going to have dialysis, whether they're going to get appropriate symptom management, all of those need to be done based on the patient's wishes.

00:36 There have been studies to show that sometimes when patients have a DNAR order in place, it does impact on other aspects of their care but it should not We should really have separate discussions with the patients about those other aspects of the care which should only apply to the cardiac arrest, the pulmonary arrest, and whether or not we're going to do CPR.

00:59 It's also important that, you know, we revisit these decisions overtime.

01:05 So, again, this is sort of prospectively doing informed consent with the patient before we actually need to institute the treatment, in this case, the CPR.

01:16 So, a person might make a decision at a particular point in time, I want to have resuscitative measures, we might otherwise call, you know, being full code.

01:24 But then, as their condition changes or their clinical circumstances change in other ways, we revisit and maybe they would decide, no, I do not want CPR in this situation.

01:38 And there may be, you know, times where it goes, you know, the person's incredibly ill, you know, very sick.

01:44 We don't think CPR would be successful.

01:47 Maybe they're septic but maybe you give them the proper antibiotics.

01:52 Their sepsis improves. Their overall condition improves.

01:56 Maybe while they were septic, they decide or their family members decided against CPR.

02:01 But now that they've recovered, they said, "No, I would want to attempt resuscitation.

02:06 I'm doing better. I want to see if I, you know, can continue to - on the road to recovery.

02:13 Another thing to consider is maybe patients have put in orders to not have resuscitation.

02:20 But then, they're going in for a procedure, either a diagnostic procedure or a surgery or an operation and there are going to be times where they're going to need to be on a ventilator for instance for general anesthesia.

02:35 So, the effects of the anesthesia might lead to cardiopulmonary derangement or even, you know, cardiopulmonary arrest.

02:44 In that very controlled environment, it might be possible for an anesthesiologist to reverse the effects of the anesthesia, you know, on its effects on the heart or on the breathing.

02:54 And bring back the heart rhythm for instance, return circulation.

03:00 So, the patient needs to be asked preoperatively, what would you want done with regard to resuscitation measures? Perhaps they had prior made the decision for do not attempt resuscitation.

03:11 Now, they're going in for an operation.

03:13 It shouldn't be a default that they automatically go to having resuscitation.

03:17 They should be asked, do you want to maintain your do not attempt resuscitation order or do you want to suspend it for the period of the procedure or the operation? And then, we can reinstitute it after the procedure.

03:30 So, this, again, is an informed consent process you're trying to figure out what are in alignment with the patient's wishes.

03:37 Another consideration with regard to DNAR orders is times when the family disagrees with preestablished orders about resuscitation.

03:47 So, take example, of a patient that makes a decision for DNAR.

03:52 They've had a conversation with their physician while they had capacity and came to the conclusion that CPR would not be in their best interest.

04:01 So, a DNAR order is placed. The patient then loses capacity and now, they have a surrogate decision-maker that has to come and make decisions.

04:12 The family may say, "Well, no, we want to reverse that earlier DNAR order and have the patient receive resuscitation." It becomes a very tricky circumstance in clinical medicine.

04:26 No easy answer about how to resolve these kind of issues.

04:30 I would say that legally and ethically, if you know that the patient has clear wishes, you've had a conversation with them, and you know that a DNAR order is consistent with their wishes and their preferences, you should try to uphold those wishes and say to the family, "I'm sorry.

04:48 My job as a clinician is to respect the patient's wishes.

04:53 Their wish was for no CPR. I need to follow-through with that." The family may object but, again, if their role is to speak to the patient's preferences and values, they should also honor what the patient said previously about DNAR and keep the DNAR orders in place.

05:14 So, it's a complicated area. There's only one particular order, one particular kind of life-sustaining treatment but it comes up often enough that we need to have a strategy about how to have these discussions with the patients and families.

05:27 And as I said, I really see this as an informed consent process.

05:30 There's either informed consent or informed refusal for CPR.

05:36 It should be based on the patient's values.

05:39 So, you should always start with the goals of care discussion about who the patient is, how they live their life, what's important in their life, what are their health values, what are the things they're hoping to achieve? Put that in the context of their medical condition.

05:54 Know what the chances of success might be if CPR in that, you know, particular condition and then, reach a decision together about what's going to be in the best interest of the patient.