DNAR - Do not ATTEMPT resuscitation

[Guest thatuvicguy]

I came across this letter in the NEJM and wondered if this has filtered down at all to other hospitals. I guess in a way it is splitting hairs but the author makes a good point about the importance of communicating clearly with patients and their relatives.

 

Anyone know if DNAR rather than DNR is being used at Canadian hospitals? Thoughts?

 

Cheers,

thatuvicguy

 

DNAR: DO NOT ATTEMPT RESUSCITATION

 

New Engl J Med 1989; 320; 673

 

To the Editor: On December 6, 1988, the Executive Committee of the United Medical Staff of Boulder (USMB) voted unanimously to approve a name change for the medical staff's do-not-resuscitate policy. The new name, recommended by the UMSB Bioethics Advisory Board, is "Do Not Attempt Resuscitation" (abbreviated DNAR and pronounced DEE-nar).

 

This change reflects a growing realization that in-hospital resuscitation efforts are almost always futile.(1) It seems, therefore, misleading and inappropriate to use a term ("do not resuscitate") that implies that one could resuscitate a patient if one wished. After all, every other phrase that begins with the words "do not" (e.g., "do not open the door," "do not shout") implies clearly that the person being addressed has the capacity to do whatever is being prescribed.

 

This consideration is particularly important in the case of resuscitation, which has a powerful symbolic meaning:

 

The miracle of resuscitation lies in its symbolic control over death. This is dangerously potent symbolism ... Physicians should acknowledge the powerful emotional effects of discussing resuscitation, and should exercise care in the language they use... (2)

 

Certainly, the very name of the order used to effect the withholding of resuscitation efforts can be an important part of the overall process of communication and decision making. We believe the DNAR terminology offers a more honest and realistic assessment of the facts about resuscitation.

 

DAVID C. HADORN, M.D., M.A.

Boulder, CO 80302.

United Medical Staff of Boulder.

 

 

(1)Blackhall LJ. Must we always use CPR? N Engl J Med 1987; 317:1281-5.

(2)Nolan K. In death's shadow: the meanings of withholding resuscitation. Hastings Cent Rep 1987 17(5): 9-14.

[Guest DrSahsi]

Most of the places where I've worked still use DNR primarily, or will use DNR and DNAR interchangeably. It is purely a semantic difference, but the authour makes a good point in that the semantics can colour the perception of the term's meaning.

 

Clear communication with patients and relatives is possible whether you refer to it as a DNR or DNAR order. In fact, I never use either term when discussing such end-of-life issues with people. Straight up, simple, plain language is the best way to get the job done.

 

- Rupinder

[Guest Elaine I]

What exactly constitutes resuscitation? Obviously, running a code does, but what about the patient who is still breathing and has a pulse? How much can be done without "resuscitating"?

 

For example, yesterday we were called to the home of an end stage cancer patient (lung cancer metastasized to stomach and esophagus). Her breathing had gotten much worse fairly suddenly. She had significant strider in her airway, which her son stated was not her normal. She was breathing 30 times a minute, very shallowly. Her SpO2 was 77% on room air with a good wave form (up to 85% on 100% O2). There was a written DNR in place. Her son was on scene, and was reaffirming the DNR. How much treatment should be done without violating the patient's wishes? What is considered resuscitation versus treating an acute problem, which may be reversible?

 

What do you think? Thanks for sharing your opinions,

Elaine

[Guest UWOMED2005]

Usually DNR means

 

- no compressions

- no juice/electricity

- no intubation

- no ventilatory support

- no ICU stay

 

Or some combination of the above. Basic care such as antibiotics or O2 is not withheld, essentially just "extreme measures."

 

But there can be a lot of gray areas as to what to treat beyond the technical DNR. And technically, it is often felt that you should give the patient of choosing a partial DNR. When I was on medicine, this led to some ridiculous scenarios as patients and families don't have a thorough understanding of resuscitation: we had patients who wanted to be tubed without compressions or electricity, compressions but no electricity or tubes, ventilatory support without intubation, etc. The chances for most resuscitations involving young healthy people and all guns blazing are slim, the chances for a resuscitation with intubation but no electricity, compressions, drugs or ventilatory support are for all intents and purposes zero. One of the consultants was adamant that DNR was either an all or nothing proposition, but there was some disagreement with some of the other consultants and residents based on the principles of "informed consent"

[Guest McMastergirl]

There is also a difference between being "DNR" and being "palliative" or "comfort measures only." Giving someone oxygen won't save their life (in the case you referred to), but may make them more comfortable. Usually if someone is palliative you don't treat their UTI with antibiotics, or give them IV fluids to correct dehydration. You might give them buscopan to dry secretions in the lungs and make them less rattly, and narcotics/sedatives to relieve pain/anxiety.

 

We had an interesting situation with a patient on my CTU rotation last month. A 39 year old man with HIV (not AIDS) who was in hospital very sick with CMV colitis, and dehydration secondary to refusal to have IVs put in. He was quite ambivalent about living/dying. He refused his meds and bloodwork, yet insisted on being a "full code." I got called one night because he was bleeding quite briskly from his rectum, but he refused a central line although we explained to him that without one he may bleed to death. He said he would take a peripheral IV only, and we were lucky to be able to get one as his veins are so collapsed from being dry.

 

Eventually he decided to be DNR, and in this situation we also made him palliative, because he was clearly dying. If he wanted to be DNR but not palliative then he would have to agree to treatment which he clearly was not compliant with.

 

He died 2 days later. We think he finally just gave up.

 

So to summarize,

1. DNR means no CPR/defibrillation/intubation/ICU admission (patients usually interpret this as "no heroic measures")... if patient suddenly "codes," no code is called

2. When DNR but not terminal, usual treatment is given (eg diuretics for heart failure)

3. When terminal, can be made palliative, which means only comfort measures are given and no life-prolonging measures such as IV fluids or antibiotics

4. When terminal but not DNR, that's a situation you don't like to see... in my experience most often happens when the patient is elderly and demented and the family is in denial about the seriousness of the situation, OR for religious reasons ???

 

At least that's my take on it. It's not black and white and I'm no expert. But in the past month or so as a resident I've thought about this quite a bit because of the types of patients I've been taking care of.

[Guest UWOMED2005]

When terminal but not DNR, that's a situation you don't like to see... in my experience most often happens when the patient is elderly and demented and the family is in denial about the seriousness of the situation, OR for religious reasons ???

 

To that I'd like to add misunderstanding as a major cause for refusal of DN(A)R. This comes in a couple of common forms. One, patients and families often have a poor notion of what a "hail mary" attempt a code blue is. It rarely succeeds even in people with healthy bodies, let alone those terminally ill. And even when it succeeds, often times the patient has suffered a serious hit to their brain and simply is not the same person. This is aggravated by the high resuscitation success rates demonstrated in Hollywood movies and episodes of ER. It often leaves us with the impression that resuscitation procedures are miraculous and can restore someone to full health.

 

Second, some patients are under the impression signing a DNR means nothing more is done - including comfort measures. They sometimes are worried signing a DNR allows the medical staff to abandon them.

 

Third, sometimes families don't understand what is going on with their family members. I was witness to a case where a newborn baby had suffered a hypoxic hit to the brain sometime prior to birth from a teenage mother. The MRI, EEG and neuro exam were all a mess. The baby had essentially no living brain left - as one member of the team put it "this baby is already in heaven, the body just hasn't gotten there yet." The grandmother however, was convinced some intact primitive reflexes were evidence the baby would be fine, and for religious reasons, was adamant about the baby's right to life and wanted full measures provided. It is unlikely this baby will survive past a year of life, and inappropriate attempts to resuscitate this baby will probably only prolong the parents' suffering.

 

This misunderstanding can be sometimes overcoming by a detailed and well laid out (in layman's terms) discussion with the patient and the family. But not always. The issues are extremely complex and the ethics are often clouded in gray.

[Guest Elaine I]

Thanks for the info. In the above situation, we consulted with the son about his interpretation of how much treatment was to be done for his mother, given the DNR. We then scoped the patient, and suctioned down as far as the vocal cords (but did not intubate). Much of the patient's respiratory distress resolved, and her SpO2 rose to 95%. Based on the son's wishes, we believe the treatment was appropriate. However, had the son not been present, we were not sure whether the treatment rendered would have been considered "resuscitation".

 

Elaine

[Guest McMastergirl]

I agree that misunderstanding is a common reason for refusal to make someone DN(A)R. I think the onus is on us as medical professionals to make sure the patient/family fully understands what DNR means, and they should be told that resuscitations are rarely successful, and when they are, the patient's quality of life is almost never restored.