Illustration to discuss a “do not resuscitate” (DNR) order when clinicians judge that they should recommend it to the patient/surrogate.
It is the medical clinician’s role to define and recommend what a reasonable plan of care is, based on a patient’s prognosis and goals.
When making a recommendation is proper
The clinician decided that it is appropriate to recommend a DNR order based on (A) careful assessment of a patient’s hopes, values, fears, and care goals in light of his/her knowledge (typically poor) of the prognosis, and (B) the medical judgment that attempted resuscitation would not help the patient to have a dignified death or to recover fully, or something in between.
If a patient does not understand or accept the provided information about their possible future course, it is critical to continue working with a grieving patient/family to help them understand or accept their prognosis, before addressing resuscitation orders.
Making the recommendation
- It’s advisable to link the discussion about code status (the level of medical interventions a patient wishes to have started if their heart or breathing stops
) with the recommendation for a DNR order, as opposed to asking the patient what they want.
- It is necessary to review preceding documentation and clarify the patient’s understanding. It is basic to use only terms that the patient / family understand and recognize.
- It is necessary to highlight what is desirable to do before discussing what is not suggested to do. It is not necessary to describe the physical act of resuscitation – the reason for not try it is its inadequacy in restoring a patient to good health.
- Intense emotions are predictable; it is necessary to respond empathically and continue the discussion based on how the patient responds. A patient may disagree with the recommendation: it is imperative to avoid becoming entrenched, and try to refocus on the patient's underlying values, goals, and emotions to better understand what underlies their objection.
- A few patients will request explanations of what to expect with CPR efforts, intubation, or the dying process without those interventions. It is essential to clarify the adequate available resources to have a dying patient comfortable and free from pain, dyspnea, or anxiety.
See reference for more information.
Adapted from Goldish A, Rosielle DA. Recommending a do not resuscitate order for patients with advanced illness. Palliative Care Network of Wisconsin. Fast facts and concepts #366. Internet. Accessed on December 27, 2018.