Living Wills & DNR: Is Patient Safety Compromised?

Human Life Review, Fall 2007 by Mirarchi, Ferdinando L, Conti, Lucia

The most common trigger terms used in living wills are terminal condition and persistent vegetative state. Defining these two triggers can be a challenge for the physician, which in turn can lead to the faulty implementation of the living will. Correctly defined, a terminal condition is any health condition that does not respond to sound medical treatment and will result in the patient's death, and a persistent vegetative state is a condition in which the patient is not aware of his/her surroundings and has lost the ability to think.1 Patients in a persistent vegetative state have lost their ability to speak or respond to commands and therefore cannot communicate their wishes for health-care treatment. A persistent vegetative state is often the result of a metabolic injury. In most states, it is required that two physicians document that the patient has a terminal condition or is in a persistent vegetative state. It is important that those physicians remember that stabilization is the first priority in an emergency situation, therefore providing enough time to assess the patient and diagnose her condition.

That goes for living wills. DNR orders are different, in that they apply only to the act of resuscitation-they do not control the acts of any other life-saving treatments. DNR policy should ensure that the physician understands that when a patient has a DNR code, there are no implied conclusions concerning any other treatment options. A DNR order represents the patient's wishes that no medical interventions be taken if they are found pulseless or apneic; but despite this definition of what a DNR code status implies, many published studies have supported the theory that DNR patients receive less aggressive care than those patients without a DNR code status.

Beach et al. studied the effect of DNR orders on the ability of physicians to make decisions on life-sustaining treatment. The study confirmed that physicians were less aggressive with DNR patients and were less likely to transfuse, transfer their patients to the ICU, order diagnostics tests, intubate, and utilize aggressive critical-care monitoring and procedures.2

Further supporting the theory, Keenan et al. reviewed the influence of DNR orders of patients admitted to surgical intensive-care units at a cancer center and found that the order resulted in less medical interventions and chart documentation.3 Bedell et al. also demonstrated that DNR orders are frequently entered on patient charts by physicians without any discussion with the patient about the order or informed consent from the patient, despite the patient's being competent to discuss the topic.4

The physicians' tendency to provide less intensive treatment to DNR patients also carries over to the nursing care. Thibault-Prevost et al. assessed the perceptions of a DNR code status of critical-care nurses and found that 47 percent failed to distinguish the DNR order from other end-of-life decisions, 72 percent felt that a DNR code status translated into the patient not wanting to receive any aggressive medical interventions, and 65 percent felt that a patient with a DNR should not be admitted into the ICU.5 Henneman et al. supported these findings by concluding that nurses were significantly less likely to perform physiologic monitoring, modalities, and interventions on patients with a DNR code status.6 Other supporting studies have also concluded that a patient's increasing age and DNR order significantly decrease the aggressiveness of nursing care and that nurses delay notifying physicians of significant changes in a patient's clinical status.678