Ethical Issues: Advance Directives and DNR Orders
Christy Price Rabetoy, Department Editor

Holly Favero, MSN, RN, CNN, BC, ACNP, is a Center Manager of an RMS Lifeline Vascular Access Center, Allen Park, MI; and a member of ANNA’s Michigan Chapter.

This article is a summary report from an interview with a nurse who is employed by a major dialysis chain. She prefers to remain anonymous. Apparently within this chain there are two possible corporate provisions to govern the care of patients who have a cardiopulmonary arrest in the dialysis unit.

The first provision recognizes that there will be situations where “do not resuscitate” (DNR) orders are appropriate. After thorough and careful consideration, a DNR will be honored by the facility in the event that the medical team, the patient, and the family agree that the DNR should be implemented. Adequate documentation is necessary to support the order. A DNR order must be clearly defined and reviewed quarterly.

The second provision, not withstanding the above, states the facility governing board believes the dialysis unit is not an appropriate location for a patient to forgo life-sustaining procedures and die. This provision takes into account and describes situations that could precipitate a cardiopulmonary arrest, that is, hypotension from excessive fluid removal or transient electrolyte imbalance. It acknowledges there may be some occurrences in a dialysis unit that result in a cardiopulmonary arrest secondary to human error, such as air embolism. Additionally, the facility may not have sufficient privacy to allow the patient a death with dignity. This provision highlights the emotional distress potentially suffered by family members and other patients. Therefore, every patient treated at the dialysis unit is presumed to consent for full cardiopulmonary resuscitation (CPR) and 911/emergency personnel are called in the event of a cardiopulmonary arrest, despite a DNR order in the patient’s chart.

After many years of clinical experience in nephrology nursing and several deaths in a dialysis unit, this nurse continues to agree with the second provision. She strongly feels that patients deserve an explanation regarding enforcement or non-enforcement of their advance directives and especially their wishes for a DNR order. The renal care team has collaborated on a letter to the patients, and everyone has been made aware of the patient’s wishes. The renal care team feels that the dying process is inappropriate in a dialysis facility. Allowing a patient to die in the unit with the new HIPAA rules becomes even more problematic with the friendships that develop among the patients. Trying to explain this mandate for confidentiality to other patients under these conditions is extremely difficult.

Advance directives vary state by state. It seems patients must have every directive in place to have their wishes followed at the required time. However, patients are never sure if what they are requesting is what they really want. Cardiopulmonary arrest, death, and unusual occurrences may cause additional stress in an already stressful environment. Therapeutic and good decisions are impaired when nurses and staff have mixed feelings or religious concerns and feel forced to follow a DNR order. Attempts at conflict resolution are not always successful, and some nurses remain very uncomfortable. Some nurses are not comfortable with a policy of not attempting to perform CPR, while others are uncomfortable with not honoring a patient’s desire for no CPR. 

Ultimately, the patient should come first, but it may be difficult to decide if the patient’s wishes are being met. This nurse thinks it is important that the staff delivering the care be comfortable with not honoring a DNR in a dialysis unit. She feels it is good to have two choices as her corporation provides, but she would be more comfortable having only one policy.

Honoring DNR Orders in the Dialysis Unit: Implementing
a Policy
Debra Castner, MSN, RN, CNN, Advance Practice Nurse, Ocean Renal Associates, Toms River, NJ; and a member  of ANNA’s Garden State Chapter.

Honoring “do not resuscitate” (DNR) orders never seemed an issue from a staff nurse position.  However, my role as a nurse practitioner has made me realize how inconsistent nephrology practice has become. Hospital units generally have a DNR protocol in place. Many private units do not recognize DNR or no CPR requests. It is ironic that nurses and social workers take the time to ask patients their preference regarding CPR, and then have them sign a form that states the patients understand that the DNR will not be honored! One unit did recognize DNR orders, but the staff had no idea what the policy actually covered, who was to be called, or what to do with the body.

Many patients and families were in despair at not being allowed to experience the end of life in the way they planned. This discussion occurred many times, and I always promised we would respect their wishes of NO CPR in the dialysis unit should I be present when the incident occurred. The problem was I could not possibly predict when to be in the right place at the right time. 

As a result of this predicament, I met with the medical director. We initiated discussions about DNR orders and end-of-life care. We agreed to start collecting information and share it with the facility administrator. At every opportunity, I shared articles, books, and described conversations I had with a patient or family member who wanted a DNR. I was mindful of “putting a face on the problem” by exploring the dilemmas and circumstances these patients and families were facing.

I asked to see the No DNR policy and found there was none locally or within the corporation. It was evident that a policy clearly stating what would be done regarding DNR orders was needed, and here was the opportunity to influence change. The facility administrator and I reviewed policies I had collected from other dialysis facilities, hospice programs, and the “DNR in the Dialysis Unit Model” available from the Promoting Excellence in End-of-Life workgroup. We started our “DNR in the Dialysis Unit” draft over several meetings and added the social workers and nurse managers to our team. It has evolved into an excellent professional experience for all. We have completed a plan for pronouncing a patient’s death, providing necessary legal forms, and the provisions for the care of the deceased patient.

It has been a lengthy process, but honoring DNR orders is not a policy that you can just write and put in place. The renal care team is now ready to proceed with staff training and then patient education. We are teaching and learning together by sharing books, articles, and real life patient experiences. Working on this project has helped us review other related issues such as approaching patients to obtain advance medical directive information and resource development for a unit based ethics committee. It is a work in progress, and I feel fortunate to have a group of dedicated professionals who are willing to put the real life issue of DNR out in plain view and work toward a solution for our patients and families.

My recommendations for others in similar situations are to research the subject, find out who in the unit would be allies for change, take your time in the planning phase, and realize this is a complicated and emotional subject.

Additional Reading
Moss, A., & ESRD Workgroup Members. (2003). Promoting excellence in end-of-life care. A National Program Office of the Robert Wood Johnson Foundation, 56-61.

The Management of Cardiopulmonary Arrests in Chronic Dialysis Patients
Ronald Miller

Ronald Miller, MD, is Clinical Professor of Medicine Emeritus at the University of California, Irvine in Irvine, CA; and Director of the Program in
Medical Ethics Emeritus.

The management of cardiac and/or pulmonary arrests (CPAs) that occur in chronic dialysis patients (especially those that occur in free-standing outpatient dialysis units) has been paternalistic. As for all CPAs that occur in hospital or that occur in emergency circumstances, cardiopulmonary resuscitation (CPR) is the paradigmatic example of a treatment for which consent is presumed rather than requested in advance. And, as for CPAs that may be iatrogenic (e.g., those that occur during surgery or during interventional radiology procedures), physicians have often performed CPR even when the patient has a do-not-attempt-resuscitation (DNAR) order or request - this despite the well-established constitutional right to refuse medical treatment, even life-saving treatment (Cruzan v. Director, 497 U.S. 261 [1990]).

Rationales (largely rationalizations) include: (a) belief that the patient would want his/her DNAR preference overridden (because of greater chance of successful resuscitation without neurologic damage when the arrest occurs during dialysis and is promptly witnessed), (b) fear that other patients would be emotionally devastated witnessing a death without an attempt at resuscitation, (c) alleged inconsistency between intermittent dialysis to prolong life (prevent death) and a DNAR request (to allow death) that was a common argument in the past for suspending DNAR orders during surgery and anesthesia since they are the epitome of “resuscitation,” (d) the lack of a secluded area in the dialysis unit to harbor a corpse, and – I believe – (e) fear of liability for a death on dialysis. Although there is some validity to most of these arguments, and in individual cases one or another might be determinative, in general these arguments are insufficient to justify overriding a competent patient’s informed request not to be resuscitated (Germain & Cohen, 2001; Ross, 2003). Space limitations preclude refutation here, but the cited articles are convincing.

Of course, patients need to be informed. Patients’ decisions regarding CPR/DNAR are greatly influenced by their knowledge of the probability of survival (Choudhry, Choudhry, & Singer, 2003; Murphy et al., 1994), and there are data regarding the outcome of CPR in chronic dialysis patients (Karnik et al., 2001; Moss, Holley, & Upton, 1992; Tzamaloukas, Murata, & Avasthi, 1991).

Many patients are misinformed and believe CPR is much more likely to be successful and much less likely to result in substantial, even permanent, complications (Diem, Lantos, & Tulsky, 1996; Karnik, et al., 2001; Moss, Hozayen, King, Holley,  & Schmidt, 2001). 

Indeed, misinformation contributes to patient attitudes, and for nephrology professionals to engage in meaningful discussion with dialysis patients about CPAs, CPR, and DNAR they should review the extensive literature (Diem et al., 1996;  Hijazi & Holley, 2003; Holley, Finucane, & Moss, 1989; Moss et al., 2001; Quintana, Nevarez, Rogers, Murata, & Tzamaloukas, 1991).

Nephrologists also need to understand physician attitudes and biases concerning iatrogenic cardiac arrests (Casarett & Ross, 1997; Casarett, Stocking, & Siegler, 1999; Christensen & Orlowski, 2000) and regarding CPAs in dialysis patients (Foulks, Holley, & Moss, 1991).  Dialysis nurses have many concerns, especially when they find a conflict between the patient’s right to refuse CPR and an order or policy that requires CPR (Anonymous, 2004; Castner, 2004).

Fortunately there appears to be an emerging consensus not only to provide information to all dialysis patients (about the risk of cardiac arrest especially during dialysis, the possibility of iatrogenic arrest, the statistically low-likelihood of survival and high chance of serious complications, the right to have or to forgo CPR), but also in favor of honoring patients’ preferences. The consensus is based upon attitudes of patients who wish CPR that the wishes of the minority who do not should be respected (Moss et al., 2001), detailed review of the ethical considerations (Ross, 2003), a legal opinion (Moss et al., 2001), the increasing use of advance directives to indicate resuscitation preferences and the liability in many states of ignoring advance directives, and finally professional clinical practice guidelines (Germain & Cohen, 2001; Moss, 2002).

References
Anonymous. (2004).  Advance directives vary: One corporation with two choices.Nephrology Nursing Journal. 31(1).
Casarett, D.J., & Ross, L.F. (1997). Overriding a patient’s refusal of treatment after an iatrogenic complication.  New England Journal of Medicine, 336(26), 1908-1909.

Casarett, D.J., Stocking, C.B., & Siegler, M. (1999). Would physicians override a do-not-resuscitate order when a cardiac arrest is iatrogenic? Journal of General Internal Medicine, 14, 35-38.

Castner, D. (2004).  DNR orders in the dialysis unit.  Honoring DNR orders in the dialysis unit: Implementing a policy. Nephrology Nursing Journal, 31(1).
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.

Christensen, J.A., & Orlowski, J.P. (2000). Iatrogenic cardiopulmonary arrests in DNR patients.  The Journal of Clinical Ethics, 11(1), 14-20.
Diem, S.J., Lantos, J.D., & Tulsky, J.A. (1996). Cardiopulmonary resuscitation on television.  Miracles and misinformation.  New England Journal of Medicine, 334(24), 1578-1582.

Foulks, C.J., Holley, J.L., & Moss, A.H. (1991). The use of cardiopulmonary resuscitation: How nephrologists and internists differ. American Journal of Kidney Diseases, 28(3), 379-383.

Germain, M.J., & Cohen L. (2001). Supportive care for patients with renal disease: Time for action. American Journal of  Kidney Diseases, 38(4), 884-886.

Hijazi, F., & Holley, J.L. (2003). Cardiopulmonary resuscitation and dialysis: outcome and patients’ views.  Seminars in Dialysis, 16(1), 51-53.

Holley, J.L., Finucane, T.E., & Moss, A.H. (1989). Dialysis patients’ attitudes about cardiopulmonary resuscitation and stopping dialysis. American Journal of Nephrology, 9, 245- 251.

Karnik, J.A., Young, B.S, Lew, N.L., Herget, M., Dubinsky, C., Lazarus, M., & Chertow, G.M. (2001). Cardiac arrest and sudden death in dialysis units. Kidney International, 60, 350-357.

Moss, A.H. & End-stage Renal Disease Workgroup (2002).  Recommendations to the field.  Promoting excellence in end-of-life care. A program of the Robert Wood Johnson Foundation.

Moss, A.H., Holley, J.L., & Upton, M.B. (1992). Outcome of cardiopulmonary resuscitation in dialysis patients.  Journal of the American Society of Nephrology, 3(6), 1238-1243.

Moss, A.H., Hozayen, O., King, K., Holley, J.L., & Schmidt, R.J. (2001). Attitudes of patients toward cardiopulmonary resuscitation in the dialysis unit. American Journal of Kidney Diseases, 38(4), 847-852.

Murphy, D.J., Burrows, D., Santilli, S., Kemp, A.W., Tenner, S., Kreling, B., & Teno, J. (1994). The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. New England Journal of Medicine, 330(8), 545-549.

Quintana, B.J., Nevarez, M., Rogers, K., Murata, G.H., & Tzamaloukas A.H. (1991). Reaction of patients on chronic dialysis to discussions about cardiopulmonary resuscitation. ANNA Journal, 18(1), 29-32.

Ross, L.F. (2003). Do not resuscitate orders and iatrogenic arrest during dialysis: Should “no” mean “no?” Seminars in Dialysis, 16(5), 395-398.

Tzamaloukas, A.H., Murata, G.H., & Avasthi, P.S. (1991). Outcome of cardiopulmonary resuscitation in patients on chronic dialysis. Transactions of the American Society of Artificial Internal Organs, 37, M369-M370.