February 12, 2018 | Healthcare Risk, Quality, & Safety Guidance
A DNR order prohibits the use of resuscitation measures in the event of cardiopulmonary arrest (Loertscher et al.). CPR encompasses procedures used to preserve life when the heart stops (cardiac arrest) or breathing stops (respiratory arrest). For cardiac arrest, treatment may include chest compressions, electrical stimulation, or the use of medications to support or restore the heart's ability to function. For respiratory arrest, treatment may include intubation (insertion of a tube through the mouth or nose into the trachea) to artificially support or restore breathing through mechanical ventilation.
CPR may be the only medical intervention that does not require an order from a licensed provider to execute but that does require an order to prevent. State laws that define DNR orders vary with regard to whether a DNR order may be implemented when a patient is both pulseless and apneic or either pulseless or apneic. (Mirarchi et al.)
Initiating CPR is the default standard when a patient's wishes for end-of-life care are not known (Ewanchuk and Brindley; Loertscher et al.; Pontoppidan). Principles of medical ethics, standards of medical practice, facility policies, EMS protocols, and some state laws may require healthcare providers to perform CPR on all patients who have suffered cardiac arrest unless they are obviously dead or there exists a valid signed DNR order precluding CPR.
Providing safeguards to ensure that patients' end-of-life treatment decisions and DNR orders are documented accurately in patients' medical records, are made readily available, and are followed should be a high priority for quality improvement professionals, risk managers, and patient safety officers. Despite an increased focus on providing quality care for terminally ill patients, discussing, documenting, and implementing DNR orders remain problematic in many facilities.
Despite lack of training and preparedness, resident physicians frequently participate in code status discussions with patients, sometimes resulting in miscommunication and other errors regarding a patient's treatment decisions at the end of life (Loertscher et al.). An observational study conducted in three large medical facilities found that resident physicians often failed to provide patients with essential information about CPR. All of the physicians discussed mechanical ventilation, but only slightly more than half mentioned chest compressions, and less than a third mentioned intensive care. Only 13% of the physicians discussed the likelihood of survival after CPR, and none provided the patients with a numerical estimate of their odds. The discussions lasted a median of 10 minutes, with physicians dominating speaking time. Physicians initiated discussions about the patients' goals of care in only 10% of the cases and some missed opportunities to do so. (Tulsky et al.) The study was conducted in the 1990s,...