Nurses Must Lead Care Team in Interpreting DNR Orders

Do-not-resuscitate (DNR) orders can help inform the course of treatment for cancer patients during life-threatening situations, but they can also lead to unwanted care if not interpreted correctly, according to a recent commentary published in the Clinical Journal of Oncology Nursing. As the lead caregiver at the bedside, the oncology nurse plays a pivotal role in preventing missteps in end-of-life care decisions and ensuring that providers carry out the wishes of patients and families.

“The nurse must do as much as possible to clarify any ambiguities in the patient’s plan of care and to ensure that the patient, family members, physicians, and nurses all have a common understanding of the patient’s preferences and needs,” writes David G. Glenn, RN, MS, a bedside nurse on the blood and marrow transplantation unit at the University of Maryland Medical Center in Baltimore.

On its own, a DNR order conveys only that a patient does not wish to be resuscitated in the event of cardiac arrest, but does not cover other interventions that might be considered in life-threatening situations or provide details about overall goals of care, says Glenn. It is up to nurses to ascertain whether patients also have advance directives, such as living wills, which provide instructions if the patient is unable to communicate, or medical proxies, which designate others to make medical decisions on their behalf.  

The nurse must make sure everyone on the care team understands the details of directives and how they correspond to any existing DNR orders, says Glenn. Poor communication or failure to read directives closely can lead to wrongly withholding life-sustaining treatments or withholding treatments that do not directly relate to resuscitation, such as dialysis, intubation, or transfer to the intensive care unit.

In addition to being aware of patients’ advance directives, nurses should be sensitive to changes in patient preferences over time, writes Glenn. For example, patients who decide that they want aggressive treatment to stop may change their treatment plan to “comfort measures only,” emphasizing the need for nurses to be skilled in delivering palliative care.

Nurses also should be familiar with other programs aimed at reducing uncertainty surrounding DNR orders, he says. For example, the Physician Orders for Life-Sustaining Treatment (POLST) form has been adopted by 18 states. Unlike DNR orders, POLST orders are initiated by physicians and treated as medical orders reflecting patient preferences about various interventions, including cardiopulmonary resuscitation, intubation, artificial airways, and feeding tubes.

“The most important role for nurses is to assess the patient’s wishes for, and understanding of, the overall plan of care,” writes Glenn. “Because the nurse spends a great deal of time at the bedside, the nurse may be the person most likely to notice discrepancies between the patient’s and the physician’s understanding of the plan of care.”