April 7, 2011

Panel explores issues related to ‘DNR’ orders

Panel explores issues related to ‘DNR’ orders

More open discussion of end-of-life care arose with the modern hospice movement in the 1970s, but in practice, when these discussions are attempted in the hospital with sick patients or their family members, a crippling discomfort is still the norm. In these trying circumstances, achieving clarity is challenging for all concerned.

“Do Not WHAT? DNR Orders in Policy and Practice,” was the topic of the Spring Ethics Grand Rounds at Vanderbilt University Medical Center, held Tuesday in Light Hall.

The panelists agreed that documentation aimed at communicating patient directives can sometimes introduce undue complexity and obscure matters for the patient care team.

They also stressed that Do Not Resuscitate (DNR) orders have a more circumscribed purpose than people generally realize, with both family members and caregivers tending mistakenly to equate a DNR order with the establishment of end-of-life care.

The panelists included Mohana Karlekar, M.D., medical director of Palliative Care; Christine Kennedy, MSN, R.N., administrative director of inpatient medicine at Vanderbilt University Hospital; and Lee Parmley, M.D., J.D., executive medical director of Critical Care.

The three were part of a group that drafted a new VUH policy on DNR orders, now awaiting approval.

The policy supports better communication of both DNI (do not intubate) and DNR orders and helps spell out the distinction between these orders and end of life care. (A similar policy is under development for Vanderbilt pediatric patients.)

DNR orders are, if anything, underused.

According to Karlekar, doctors are no different from anyone else in preferring consensus, and may be prone to concede to a family request for cardiopulmonary resuscitation even when a non-resuscitation order is medically indicated.

“You have to have a balanced discussion. You have to talk about what things you'll do, and, most importantly, what the arrest represents. And I think this is where most of us miss the boat.”

If a doctor provides proper context in recommending a DNR order, “Most people will say, 'Do the things you think are going to help and don't do the things you think are not going to help,'” Karlekar said.

Parmley said a DNR order, in his opinion, is not a statement that caregivers are going to back off and provide something less than very aggressive care.

“I commonly will be talking about putting in a pulmonary artery catheter or nonconventional modes of ventilation at the same time I'm talking about a do not resuscitate order.

“A do not resuscitate order is not an end of life care plan,” Parmley said.
Kennedy said, “What does a DNR mean to the nurse on the floor? Does it mean, 'The patient's blood pressure is dropping, but I'm not going to call for help because the patient's a DNR.'

“We want to get away from that thinking. The DNR really only addresses what happens if that patient is in an arrest.”