DNR ORDERS
From the 10th Annual Hepato-Biliary Update, sponsored by the Johns Hopkins University School of Medicine
Glenn J. Treisman, MD, PhD, Associate Professor of Psychiatry and Behavioral Sciences, and Internal Medicine,
Johns Hopkins University School of Medicine, Baltimore
| Case: 60-yr-old man with known renal cell cancer; after nephrectomy, oncologist told patient cancer metastatic and that
patient should make arrangements for his death; patient retired but continued to work as hobby; 2 yr after nephrectomy,
patient stopped working abruptly (September), which was out of character for him; daughter visited him in
October and found house in disarray; patient promised to do better; patient admitted for dehydration in November
and readmitted in December; entered nursing home in January; diagnosed with depression in February and started
on paroxetine (Paxil); stopped walking in March; became incontinent in April; referred to geriatric outpatient service
for dementia in May; had evaluation in June, and tests ordered; none of tests performed because patient had
elaborate do-not-resuscitate (DNR) order and physicians decided patient with DNR order did not need tests; in July,
daughter had father admitted to hospital for evaluation of dementia
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 | Speaker’s interaction: resident requested speaker’s signature on DNR order before seeing patient, insisting that nurses
wanted it done right away; speaker asked to review case, examine patient, then sign orders; patient’s score on Mini
Mental Status Examination (MMSE) was 11 (30 normal); patient could barely answer questions; patient demonstrated
that he wanted to walk but did not know what to do; patient incontinent; triad of incontinence, subcortical dementia,
and apractic gait suggests normal pressure hydrocephalus (NPH); neurology and medicine consultations,
tests, computed tomography (CT) of head, and laboratory tests ordered; digitalis level 2.6 ng/mL, and creatinine 2.6
mg/dL; hydration reduced creatinine and digitalis levels and increased MMSE score by 2 points; next morning,
medicine resident delivers lecture on medical futility, and neurology resident cancels order for head CT; CT finally
obtained; patient has enlarged ventricles and all signs of NPH; speaker orders large-volume lumbar puncture (LP)
and neurologic consultation; resident tells speaker later that day that large-volume LP not done because patient not
competent and advance directive forbids invasive procedures; speaker argued LP minimally invasive and advises
call to daughter for permission; after second large-volume LP, patient got up and walked 2 steps, and MMSE score
went up to 14; patient clearly looked better for 2 to 3 days; neurologist confirmed diagnosis of NPH; speaker ordered
shunt, but advance directive did not address this particular circumstance; neurosurgery said shunt would require
court order because no provision in advance directive about this procedure; patient waited 40 days while legal
issues debated; finally, daughter threatened lawsuit if shunt not placed; patient eventually walked out of hospital and
lived independently at home for several years; he eventually died of heart disease
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| Medical decision making: like any medical intervention, do-not-resuscitate (DNR) orders have risks, benefits, therapeutic
effects, and side effects; must weigh advantages and disadvantages of procedures; doctor-patient relationship
has unequal balance of power (physician has all power, patient has none); this type of relationship can exist only if patient’s
interests put first by physician (can be corrupted by physician and by outside social and financial pressures)
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| DNR orders at Johns Hopkins: DNR orders first appeared in medical records in 1976, but policy not adopted until
1982; first major incident occurred in 1984 when hyperalimentation discontinued on patient without physician’s order
because hyperalimentation team determined patients with DNR orders should not receive hyperalimentation; patient’s
physician complained, and decision made that physician in charge of patient should decide; in 1988, medical board
told that in patients with AIDS, house staff sees DNR orders as sign to do nothing, vs everything if no DNR order exists;
suggestion that DNR orders should not guide rest of case; living wills initiated by physician thought to be better
approach; in 1989, DNR policy clarified to say that codes are all or none; in 1990, patient with brisk gastrointestinal
(GI) bleeding taken to GI suite, only to be returned without treatment because clinicians saw DNR order and determined
if patient stopped breathing during sedation, they could not resuscitate him; ultimately decided that patients
with DNR orders can be resuscitated if accidentally killed with too much sedation
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| Scope of problem: patients with terminal cancer who are dying should not be given chest compressions when they
stop breathing, but who decides and how is decision made? ambulance crew cannot decide, because they are not physicians;
unless DNR order exists, crew must attempt cardiopulmonary resuscitation (CPR) on elderly nursing home
patient found not breathing; American College of Physicians ethics manual says DNR order should not affect any
other aspect of patient’s care; DNR order meant only to prevent patient known to be dying from receiving chest compressions,
but in practice, it entirely changes way medical system relates to patient; literature—3500 papers published
on subject of DNR orders, but only ≈100 have data on risks and benefits
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| Why DNR orders exist: 25-yr-old woman, Nancy Cruzan, in car accident that left her in persistent vegetative state;
family sought cessation of tube feedings; hospital refused without court order; Supreme Court ruled in favor of state,
saying incompetent patient must have left clear and convincing evidence of her preferences to be deprived of food and
water; hailed as tremendous victory by state of Missouri and by right-to-death advocates who said, “if you have left
clear and convincing evidence, you can ask your doctor to do anything,” and that patient autonomy most important
consideration
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| 1991 patient self-determination act: resulted from Cruzan case; requires all patients to be advised about advance
directives and legal rights to self-determination of health care (did not say how, just that it had to be done); “it’s the
ways in which these [laws] affect our practice that are being given little consideration”; DNR orders help most when
physician already knows what to do, and interfere in cases when best course of treatment for patient unclear; patients’
interests and values when competent may be different from those they have when advance directives implemented
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| Advance directives in life-sustaining care (1971 study): 175 patients in large nursing home had advance directives
written; physicians ignored advance directives 25% of time and followed them 75% of time; when advance directives
ignored, physicians did less than what advance directives said in 25% of cases, more in 25% of cases, and 50% of
time directive ignored because patients changed their mind; majority of time, physicians did less than called for by advance
directives “because it was silly”; family of incompetent patients wanted treatment withheld more often than
competent patients in similar situations; family members and physicians do not know what patients want without consulting
patient directly; patients change their mind, depending on many factors, many of which have nothing to do
with their illness (eg, weather, what’s happening with their friends, how recently they have eaten, mood, health of
spouse); patients suffering from depression want interventions withheld but want interventions performed when depression
treated; patients whose depression scores did not change nevertheless changed their choices regularly and
sometimes randomly (advance directive form so detailed that difficult to fill it out same way twice); incompetent patient’s
best interests should take precedence over most thoughtful choices patient made when competent (Wolfe et al,
1991)
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| Patients close to death: frail elderly people with severe illness were asked how much time of their remaining days
would they give up if they could be completely healthy; numbers surprisingly low (10%, 20%, many said none);
“people, when they do these advance directives, don’t know how it’s going to be when they’re sick, and they also
don’t know how it’s going to be when you get them well”
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| Atkinson study (1994): Active Physiology and Chronic Health Evaluation (APACHE) score predicted 137 patients
certain to die; treated all; 131 died in 2 days, 6 survived; cost $250,000 per survivor; save most money by letting patients
die who have 50/50 chance of survival; not much money saved by treating all patients in certain-to-die group
where only 5% survive
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| Outside pressure: husband of patient in persistent vegetative state pressured by clergy and health care professionals
to take wife off ventilator because room needed for other patients; wife eventually recovered (not expected); “we have
those cases, and you will be pressured in those cases to stop treatment”; family members morally required to make
best decision based on what’s best for all concerned, not simply what is best for themselves; many times, family members
have greater interest than patient in which treatment option exercised, eg, patient who requires much care by family;
in such cases, interests of family may override those of patient; physicians need to hold interests of patient above
those of family members, sometimes making them unpopular with family; case example; “sometimes you have to fight
to do what’s best for your patient”
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| Euthanasia: 1996 Lancet study (data gathered in previous 4 yr)—surveyed oncologists, their patients, and general
public; showed 23% of physicians and 66% of public think it permissible to kill patient with unremitting pain; 15%
of physicians and 50% of public and patients thought euthanasia permissible if patient burden on family; 6% of physicians
and 33% of public and patients think euthanasia acceptable for patients with functional disability; patients
with cancer and severe pain, and those who are religious less likely to endorse assisted suicide and euthanasia; 20%
of patients and 25% of public said they would change physicians if they discovered their physician had provided
such services; patients with worst prognosis were least likely to endorse assisted suicide and euthanasia, and most
likely to say they would change physicians if they discovered their physician had provided such services; in telephone
survey, people who would consider assisted suicide and euthanasia are those who screen positive for depression;
2% of oncologists admitted on telephone that they had killed patient, and 20% admitted assisting patient with
suicide; nonpsychiatric physicians may allow life-ending interventions when treatment of depression may be more
appropriate
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| The Netherlands: physicians not prosecuted for euthanasia and assisted suicide if they follow guidelines, ie, 1) patient
must repeatedly and explicitly request it, 2) there has to be severe physical or mental suffering with no prospect of
relief, 3) decision must be well-informed, free, and enduring, 4) all alternatives must have been exhausted or refused
by patient, 5) another physician has to be consulted, 6) physician must record course of events; under second guideline,
depression acceptable reason for assisted suicide or euthanasia; in late 1980s, 5% of deaths in Netherlands either
assisted suicide or euthanasia; of deaths due to euthanasia (2%), 50% not requested by patients, but physicians
claim to know patients would have wanted to die if they had been able to speak; however, many papers show physicians
and family members do not know what patients want without consulting them
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| Slippery slope: patients can refuse any intervention; discontinuation of heroic life support; physician-assisted suicide;
voluntary or involuntary euthanasia is over the line, “and that’s where we are in Oregon and the Netherlands”; data
show overwhelmingly that advance directives and DNR orders decrease hospital costs, so there is subtle economic
pressure on physicians to use these interventions; physicians must weigh risk and benefit for their patients; Nazi
holocaust—started with psychiatrists killing mentally ill patients because they had no one to defend them; then killing
of Jews, gypsies, and other “defectives” began; modern-day victims are demented elderly patients and psychiatrically
ill HIV patients (their treatment being rationed to save money); physicians who ran Nazi killing centers allowed to
sign charts with pseudonym; “don’t do anything in medicine that requires you to lie about your name”
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| Conclusion: DNR orders have intended and unintended consequences that were not foreseen when they were established;
one consequence is decreased intensity of care; most patients do not understand what DNR orders mean; decisions
about future medical care affected by patient’s state of mind, unlikely to be enduring, and not shown to be
superior to physician’s good judgment; DNR orders have broader implications than simply sparing chest compressions
(impact cost of care, burden physicians, cause discomfort to loved ones; these factors can corrupt their use); enduring
doctor-patient relationship where doctor and patient work together to make end-of-life decisions is current
standard of care that is being eroded by today’s delivery system (“knowing someone for lifetime allows you to advocate
for them; knowing someone for 8 min, on call, doesn’t allow you to know much about anything”); physician
must advocate for patient’s best interest; speaker not opposed to DNR orders, but opposed to their thoughtless application
and their insinuation into medical armamentarium with little consideration about their potential risks; “if it
was me, I would rather have anybody in this room, no matter how postmodern a doctor you are, make the decision
than have it made by a piece of paper that I signed not knowing what I was doing”
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Educational Objectives
| The goal of this program is to educate the listener about do-not-resuscitate (DNR) orders and advance directives. After
hearing and assimilating this program, the clinician will be better able to:
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| 1. Summarize the history of DNR orders.
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| 2. Describe the Nancy Cruzan case and the law that was established as a result.
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| 3. Cite the opinions of patients who are close to death about end-of-life choices.
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| 4. Describe a case that illustrates a physician receiving outside pressure to discontinue therapy for a dying patient for
financial or political reasons.
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| 5. Give a summary of the side effects DNR orders can have on a patient’s care.
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Suggested Reading
Applebaum GE et al: The outcome of CPR initiated in nursing homes. J Am Geriatr Soc 38:197, 1990; Atkinson S
et al: Identification of futility in intensive care. Lancet 344:1203, 1994; Blackhall LJ: Must we always use CPR? N
Engl J Med 317:1281, 1987; Danis M et al: A prospective study of advance directives for life-sustaining care. N Engl
J Med 324:882, 1991; Death and dignity: the case of Diane. N Engl J Med 325:658, 1991; Emanuel LL et al: Advance
directives for medical care--a case for greater use. N Engl J Med 324:889, 1991; Fallat ME et al: Do-not-resuscitate
orders for pediatric patients who require anesthesia and surgery. Pediatrics 114:1686, 2004; McCrary SV et al:
Hospital policy on advance directives. Do institutions ask patients about living wills? JAMA 262:2411, 1989; Postovsky
S et al: "Do not resuscitate" orders among children with solid tumors at the end of life. Pediatr Hematol Oncol
21:661, 2004; U.S. Supreme Court: Cruzan v. Director, Missouri Department of Health. Wests Supreme Court Report
110:2841, 1990; Vanpee D et al: Scale of levels of care versus DNR orders. J Med Ethics 30:351, 2004; Wolfe J
et al: Symptoms and suffering at the end of life in children with cancer. N Engl J Med 342:326, 2000.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the
faculty reported nothing to disclose.
Dr. Treisman was recorded September 11, 2004, in Cambridge, Maryland, at the 10th Annual Hepato-Bilary Update,
sponsored by Johns Hopkins University School of Medicine. The Audio-Digest Foundation thanks Dr. Treisman and the
Johns Hopkins University School of Medicine for their cooperation in the production of this program.
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