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No halfway measures

Partial DNRs cause problems for physicians, patients

From the June ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Charlotte Huff

The creation of a do-not-resuscitate (DNR) order involves some of the most difficult decisions a patient may ever face. Anxiety about the task may lead some to start picking and choosing among interventions, resulting in what's sometimes dubbed a partial DNR order.

But that approach can cause more problems than it resolves, according to hospitalists and palliative medicine specialists. For one thing, what the patient selects may not be feasible clinically. The tailored paperwork can also serve as a red flag, revealing underlying patient fears or insufficient education by physicians, they said.

Photo by Thinkstock.

Photo by Thinkstock.



“To me, [a partial DNR] is a billboard that there has not been an adequate patient-family discussion,” said Stephen Bekanich, MD, a hospitalist and medical director for palliative care services at the University of Miami.

A paper in January's Critical Care Medicine, which analyzed partial DNRs, raised similar concerns, describing the orders as ethically and clinically worrisome given that neither patients nor clinicians can anticipate every possible medical scenario. To date, there's also been little data about the orders' clinical effectiveness, the authors wrote. They cited only one study, published in July 2001 in Archives of Internal Medicine, which found that none of the patients with a restricted advance directive survived. Among patients with no such resuscitation limitations, 23% lived.

To some extent, these tailored orders are a byproduct of the inherent complexities of today's medical treatment, particularly from a patient or family member's perspective, said Melissa Schepp, MD, a co-author of the Critical Care Medicine analysis. Sometimes patients or loved ones may not fully understand what “do not resuscitate” means, she said. To some ears, it can sound more like “do not treat.”

“I think that the partial DNR orders are sometimes put in place because people have fears, about say being on a ventilator for a prolonged period of time, so they will try to piece it out and just choose one thing and not the other,” said Dr. Schepp, medical director of palliative care at Saint Joseph's Hospital in Atlanta. “From there it becomes like a slippery slope, in that all of the elements of life-saving care then can turn into an [a la carte] menu.”

Partial DNR in practice

Some types of partial DNRs do make clinical sense in a small number of scenarios, said Eva Chittenden, FACP, associate director of the palliative care unit at Massachusetts General Hospital in Boston, estimating that she has assisted with the development of such orders for about 5% of her patients.

For example, a patient with lung disease could specify DNR, but not want to rule out intubation as an option. That makes sense clinically, as lung patients are more likely to need intubation and may not desire full resuscitation, she said.

Another scenario would be if a patient has designated DNR but still wants to retain the option of getting intravenous blood pressure support, via pressor medications, in the intensive care unit, she said. This might happen with a cancer patient who develops a serious infection. While the patient would like to forgo a full code, he or she might still want access to the medications in the hopes of fighting off the infection and buying some additional quality time, she said.

“These are rare situations,” she noted. “In general, partial DNR orders are not indicated.”

One particularly problematic DNR is when the patient declines intubation, but approves various measures to restart the heart, Dr. Chittenden said. If the heart is restarted, the patient may still be unconscious and require manual bagging by a clinician, she said.

But that manual resuscitation can't be feasibly continued for days or possibly weeks before the patient breathes independently again. “You could get yourself in a very unfortunate situation where at that point you would have to intubate them and not respect what they had said,” Dr. Chittenden said. On the rare occasions that a resident has presented her with this order, she has not approved it as it does not make sense pathophysiologically, she noted.

A hurdle in discussing DNR is that patients or family members may possess too rosy a view of resuscitation success, influenced in part by television depictions, said Jacqueline Yuen, MD, who begins this summer as a geriatric fellow at the University of California, San Francisco. Dr. Yuen authored a paper on DNR orders, published online in February in the Journal of General Internal Medicine.

“Oftentimes, even if patients do survive [resuscitation], they are treated in the ICU, they are intubated, they may not survive to discharge, they may have lots of complications from the procedure that may be undesirable,” Dr. Yuen said.

Her paper, as well as the January paper in Critical Care Medicine, cites a litany of studies showing how poorly patients fare. One study in the 2009 New England Journal of Medicine reported that only 18.3% of patients who received CPR in the hospital survived to discharge. Moreover, the researchers, who looked at Medicare data involving 433,985 in-hospital CPR attempts from 1992 through 2005, didn't identify any significant improvement during that time period.

In the July 2001 Archives study, which looked at patients with traditional or limited codes, the number who had some type of restriction on CPR was small—just 37 compared with 445 who received the traditional intervention. A limited code was defined as some type of advance directive restriction on one or more of the following: intubation, chest compressions, electrical defibrillation or prolonged resuscitation efforts. Of the 37, six were alive after the initial resuscitation effort. None of the patients survived long enough to leave the hospital.

Communicating alternatives

Often, a partial DNR indicates that a doctor's end-of-life discussion with a patient has broken down in some way, Dr. Chittenden said. Ideally, the physician discussion should focus less on medical procedures and more on understanding and supporting the patient's goals for his or her final days, including making a related DNR recommendation, she said.

“You are the medical expert,” Dr. Chittenden said. “You should be guiding the patient to make sure that what they opt for makes clinical sense. You wouldn't offer partial chemotherapy, if it's not going to help.”

The sorts of communication breakdowns that can result in a partial DNR order often begin with an overly blunt or aggressive conversation, or at least one that doesn't offer patients and their families sufficient opportunity to process the medical context of the decision they are about to make, Dr. Schepp said. Some doctors, she said, “are very guilty of sometimes saying, ‘Do you want us to pound on your chest? Do you want us to stick a tube down your throat?’”

Frequently, the conversation has already been too long delayed, Dr. Bekanich said. As patients become sicker, they often possess less mental ability to absorb and process all of the requisite details, he said. Their thinking also can be hampered in other ways, including by the multiple medications they're taking or by the understandably acute distress of family members at the bedside.

While Dr. Bekanich acknowledged the time constraints of hospitalist care, he stressed that in the vast majority of cases the physicians shouldn't raise the question of a DNR unless they can devote some time to becoming better acquainted with the patient and their family, to gain a better sense of their goals for their remaining time.

For example, if the patient wants to be intubated but one of her goals is to die peacefully at home with her family around, the hospitalist can delve further, Dr. Bekanich said. “You are choosing this, but that's not consistent with the goals I just heard. Where is this coming from?”

Exploring that apparent conflict may unearth related desires, he said. For example, a patient may say that she wants to be intubated. Additional questions might reveal, though, that she only wants short-term intubation until her children can fly in to say goodbye.

Other quandaries can develop when medical circumstances shift after a patient has already signed a DNR order, said Nancy Berlinger, PhD, deputy director and research scholar at The Hastings Center, a nonprofit bioethics research institute in Garrison, N.Y.

She described one scenario, in which a patient with an incurable progressive disease learns that a surgical procedure could improve his or her quality of life. The surgeon is willing to perform it. But the anesthesiologist balks at the do-not-intubate stipulation in the patient's DNR order, worried about needing quick access to the patient's airway in the event of an emergency.

“What if the wish that underlies all of this is, ‘I want the problem fixed. But I don't want to wake up on a ventilator.’ What does the surgical team, including the anesthesiologist, do about it?’” Dr. Berlinger asked.

One option, rather than tailoring the existing order, would be to temporarily suspend the DNR during the surgical procedure and then subsequently reinstate it, she said. Such an approach, though, would need the buy-in of all of the physicians involved, as well as the informed consent of the patient, or the patient's surrogate if the patient lacks capacity.

Maximizing the time

A time-pressed hospitalist may find it difficult to carve out time for a nuanced DNR conversation with every patient, Dr. Chittenden said. One alternative would be for hospitalists to mentally triage every patient under their care, asking themselves: “Would I be surprised if this person coded within 72 hours?” If the answer is no, find some time to discuss code status, she said.

Another quick screening tactic would be to ask if patients have picked a health care proxy, as well as whether they have ever had discussions about resuscitation, CPR or heroic measures. “Use a number of different terms because some patients may have heard of some, but not others,” Dr. Chittenden said. In that way, the hospitalist can quickly identify patients who already know that they don't want to be resuscitated.

As the conversation unfolds, it's important for the physician to verify that patients and/or their family members understand what is being described about medical prognosis and related decisions, Dr. Chittenden said. Focus the conversation on how the patient wants to live the remainder of his life and strive to steer clear of medical jargon, she said.

Dr. Chittenden recommends frequent checks to assess the patient's comprehension, such as: “‘I've just given you a lot of information. Can you tell me what you've heard?’”

While Dr. Bekanich prefers the physician to initiate and lead the DNR conversation, other clinicians can get involved once the patient's desires become clear, he said. He returned to the scenario of the patient who asks to be intubated until her children have arrived. Those children should be notified of their mother's wish prior to a medical crisis. If the hospitalist is too overworked, those conversations could be handled by a social worker or case worker, with the hospitalist providing backup if necessary, he said.

A poorly handled discussion is far more likely to result in bad choices, such as the patient picking and choosing interventions via a partial DNR, Dr. Bekanich said.

“Talking about this takes a lot of time and a lot of effort,” he said. He stressed that it's time well spent. “It saves a whole lot more trouble, time, resources and physical and emotional distress for everybody involved if these discussions happen at ground zero and not after some kind of serious insult to the patient.”

Charlotte Huff is a freelance writer in Fort Worth, Texas.

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