Ethical considerations in emergency department management of terminally ill patients

Do-not-resuscitate orders. Where are they in the prehospital setting?

Without a well-functioning, prehospital, do-not-resuscitate (DNR) system in place, emergency medical service (EMS) providers must resuscitate all patients who access the system, regardless of the patients' wishes and regardless of what makes ethical or economic sense. In lieu of valid documentation, it is not appropriate to withhold resuscitative measures in this critical, time-dependent situation. In order to help EMS systems implement functional prehospital DNR protocols, this paper reviews the state-of-the-art of prehospital DNR including the issues to consider when designing such a system and a discussion of the features of some of the existing systems. This review includes: 1) the basis and requirements of a DNR system; 2) legal and physical forms for DNR orders; 3) eligibility for DNR status; 4) reversal of DNR orders; and 5) inappropriate use of EMS systems for DNR patients. Finally, a more general discussion of overall resource utilization in prehospital resuscitations is presented to emphasize that implementing prehospital DNR systems is only one piece of a larger issue.

Do-not-resuscitate orders in the emergency department

PURPOSE

To evaluate the nature of the decision to write a do-not-resuscitate (DNR) order in the Emergency Department (ED).

PATIENTS AND METHODS

This is a prospective evaluation of 37 consecutive patients for whom a DNR order was written by personnel assigned to the ED of a large inner-city teaching hospital. For each patient, information was collected including who was involved in the decision, the difficulty the family or patient had in agreeing to the DNR order, acute and chronic problems, how often the patient could enter into the process, and the ultimate outcome.

RESULTS

DNR orders were usually initiated by house officers assigned to the ED (65%), and the family was usually involved (89%, mean of 1.4 family members per patient). There were no cases where significant resistance to the DNR order was exhibited by the family. The patients were generally elderly, demented, and debilitated with multiple chronic medical problems or young with malignancy or the acquired immunodeficiency syndrome and had become critically ill and unstable. Only five patients were able to enter into the decision. Discussion of DNR status had occurred previously in only 14% of patients.

CONCLUSION

Because there remains considerable reluctance on the part of physicians to discuss the DNR issue before patients become critically ill, it is often necessary for ED physicians to write a DNR order. Although the ED is not an ideal setting for discussion of DNR orders and patients and families do not generally initiate this discussion, DNR orders can be written by ED physicians after consultation with the family.