AMERICAN NURSES ASSOCIATION

Position Statement on

Nursing Care and Do-Not-Resuscitate (DNR)* Decisions

Summary: Nurses face ethical dilemmas concerning confusing or conflicting DNR orders and this statement includes specific recommendations for the resolution of some of these dilemmas. Although cardiopulmonary resuscitation has been used effectively since the 1960s (Kouwenhoven et al., 1960), the widespread use and possible overuse of this technique and the presumption that it should be used on all patients has been the subject of ongoing debate (Hayward, 1999; Lederberg, 1997). The DNR decision should be directed by what the informed patient wants or would have wanted. This demands that communication about end of life wishes occur between all involved parties [patient, health care providers [HCPs], and family; the latter as defined by the patient], and that appropriate DNR orders be written before a life-threatening crisis occurs. Background: Expectations that the Patient Self-Determination Act would facilitate communication about DNR orders among HCPs and patients led to a disappointing clinical reality, as research has shown low rates of advance directive (AD) completion and poor ability of Ads to influence physicians decisions about writing DNR orders (Hakim, et al., 1996; Jacobson & Kasworm, 1999); Prendergast, 2001). This is partly due to the confusion surrounding how written Ads are interpreted, how DNR decisions are made and implemented, and how DNR itself is defined (Hakim, et al., 1996; Heffner, et al; 1996; Teno, et al., 1998). Some have argued that HCPs focus too narrowly on the DNR order, which typically prohibits attempts to restore cardiopulmonary function in the event of a patients cardiac or pulmonary arrest. Instead, they assert that the focus should be on the goals of medical treatment, for example: Life prolongation regardless of quality; Comfort and symptom palliation; or Aggressive attempts to sustain life with the understanding that life-sustaining technology will be withdrawn if it does not meet the goals agreed upon by the HCP and patient or family; (Choudhry, 2003; Fischer, et al., 1997; Kolarik, et al., 2002; Prendergast, 2001).

Recommendations In view of the confusion and complexity that continue to surround DNR decisions and their implementation, ANA makes the following recommendations: 1. Whenever possible, the DNR decision should be a subject of explicit discussion between the patient and the family (or designated surrogate) acting according to the patients wishes, if known, or alternately, the patients best interest, and the health care team. The efficacy and desirability of CPR attempts, a balancing of benefits and burdens to the patient, and therapeutic goals should be

considered; 2. The choices and values of the competent patient should always be given highest priority, even when these wishes conflict with those of HCPs and families. An exception to this is if CPR attempts are requested via an AD or surrogate but one or more physicians determine, as allowed by state law, that CPR attempts would not be medically effective. (Ditillo, 2002); Nurses need to be aware of and have an active role in developing DNR policies within the institutions where they work. Specifically, policies should address, consider or clarify: Potentially confusing orders such as chemical code only, or resuscitate, but do not intubate; Inappropriateness of slow codes or show codes (i.e., attempts to demonstrate or mimic a response, perhaps for the benefit of family members, that stops short of a full resuscitation effort); Guidance to HCPs who have evidence that a patient does not want CPR attempted but for whom a DNR order has not been written; Required documentation to accompany the DNR order, such as a progress note in the medical record indicating how the decision was made; The role of various HCPs in communicating with patients and families about DNR orders; Effective communication of DNR orders when transferring patients within or between facilities; Effective communication of DNR orders among staff that protects against patient stigmatization or confidentiality breaches; Guidance to HCPs on specific circumstances that may require reconsideration of the DNR order (e.g., patients undergoing surgery or invasive procedures); The needs of special populations (e.g., pediatrics);

3.

4. 5.

DNR orders must be clearly documented, reviewed and updated periodically to reflect changes in the patients condition (JCAHO, 1992); There should be no implied or actual withdrawal of other types of care for patients with DNR orders. Attention to language is paramount, and euphemisms such as doing everything, doing nothing, or withdrawing

care, to indicate the absence or presence of a DNR order should be strictly avoided; 6. Exclusive of condition-specific DNR orders (Choudhry, et al., 2003), a patient who has a DNR order and who suffers cardiopulmonary arrest for whatever reason should not have CPR attempts performed; Nurses have a duty to: educate patients and their families about the use of biotechnologies at the end of life, termination of treatment decisions, and Ads; encourage patients to think about end of life preferences in advance of illness or a health crisis, to discuss them with their HCP(s) and family, and to implement an AD; communicate known information that is relevant to end of life decisions; advocate for a patients end of life preferences to be honored;

7.

8.

Nurses should participate in an interdisciplinary mechanism (e.g., interdisciplinary ethics committee) for the resolution of disputes among patients, families and/or HCPs concerning DNR orders (Casarett & Siegler, 1999).

The appropriate use of DNR orders, together with adequate palliative end of life care, can prevent suffering for many dying patients who experience cardiac/pulmonary arrest. As the primary continuous HCP in health care facilities, the nurse must be involved in the planning as well as the implementation of resuscitation decisions. Clear DNR policies at the institutional level that include the basic features that ANA recommends will enable nurses to effectively participate in this crucial aspect of patient care. *Other terms include Do Not Attempt Resuscitation and no CPR References American Nurses Association (2001). Code for Nurses with Interpretive Statements. Washington, DC: American Nurses Publishing Casarett, D. & Siegler, M. (1999). Unilateral do-not-attempt-resuscitation orders and ethics consultation: A case series. Critical Care Medicine 27(6): 1116-20. Choudhry, N.K., Choudhry, S., & Singer, P.A. (2003). CPR for patients labeled DNR: The role of the limited aggressive therapy order. Annals of Internal Medicine 138(1):65-68 Ditillo, B.A. (2002). Should there be a choice for cardiopulmonary resuscitation when

death is expected? Revisiting an old idea whose time is yet to come. Journal of Palliative Medicine 5(1):107-16. Fischer, G.S., Alpert, H.R., Stoeckle, J.D., Emanuel, L.L. (1997). Can goals of care be used to predict intervention preferences in an advance directive? Archives of Internal Medicine 157(7):801-7. Hakim, R.B., Teno, J.M., Harrell, F.E., Jr., Knaus, W.A., Wenger, N., Phillips, R.S., Layde, P., Califf, R., Connors, A.F., Jr., & Lynn, J. (1996). Factors associated with do-not-resuscitate orders: Patients preferences, prognoses, and physicians judgments. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Annals of Internal Medicine 125(4):284-93. Heffner, J.E., Barbieri, C. & Casey, K. (1999). Procedure specific do-not-resuscitate orders. Effect on communication of treatment limitations. British Journal of Nursing 8(12):810-14 Hayward, M. (1996). Cardiopulmonary resuscitation: Are practitioners being realistic? Archives of Internal Medicine 156(7):793:97 Jacobson, L.J., Kasworm, E. (1999). May I take your order: A user-friendly resuscitation status and medical treatment plan form. Quality Management in Health Care 7(4):13-20 Joint Commission on the Accreditation of Health Care Organizations (1992) Nursing Care Standards, Accreditation Manual for Hospitals. Oak Bluffs Terrace, Illinois. Kolarik, R.C., Arnold, R.M. Fischer, G.S. & Hanusa, B.H. (2002). Advance care planning. Journal of General Internal Medicine (8):618-24 Kouwenhoven, W.B., Jude, J.R, & Knickerbocker, G.G. Closed-chest cardiac massage, Journal of the American Medical Association, 1960, 178:84-97 Lederberg, M.S. (1997). Doctors in limbo: The United States DNR debate. Psychooncology 6(4):321-28 Norlander, L. & McSteen, K. (2000). The kitchen table discussion: A creative way to discuss end-of-life issues. Home Healthcare Nurse 18(8):532-9 Prendergast, T.J. (2001). Advance care planning: Pitfalls, progress, promise. Critical Care Medicine 29(2 Suppl), N34-39 Teno, J.M., Stevens, M., Spernak, S. & Lynn, J. (1998) Role of written advance directives in decision making: Insights from qualitative and quantitative data. Journal of General Internal Medicine 1998 July;13(7):439-46

Effective Date: Status: Originated by: Adopted by: Revised by:

1992; Revised 1995; Revised 2003 Revised Position Statement Task Force on the Nurses Role in End of Life Decisions ANA Board of Directors The Advisory Board of the ANA Center for Ethics and Human Rights

Related Past Action: 1. Code for Nurses With Interpretive Statements, 2001 2. Nursing and the Patient Self-Determination Act, 1991 3. Promotion of Comfort and Relief of Pain in Dying Patients, 1991
G:\POSITION\HUMANRT\DNRREVISED2004.doc

American Nurses Association 600 Maryland Avenue, S.W. Washington, DC 20024 (202) 651-7000