Which of the following is the best first step in leading a DNR discussion?
a) Ask the patient if they have completed an advance directive
b) Decide if you believe CPR to be medically indicated
c) Inform the patient that you will respect their decision
d) Tell the patient your CPR/DNR recommendation
Answer b.
Before starting a discussion about resuscitation goals, it is important for the clinician to
first evaluate the potential risks and benefits of undergoing CPR, and to decide if the
procedure is indicated for the patient at this time. It is important to recognize certain
clinician situations in which CPR in unable to restore cardio-pulmonary function to any
meaningful goal. Examples include: patients imminently dying from an expected
chronic/fatal illness, multiple myeloma with sternal involvement, and multi-system organ
failure in the intensive care unit. This determination should be the clinicians’ starting
point when beginning the discussion. Additional steps in the discussion include
elucidating the patient’s understanding of prognosis and determining patient-centered
goals of future care. After understanding what the patient’s hopes to achieve from
medical care, it is important to discuss your treatment recommendation in context of their
treatment goals. Early questioning about advance directives (answer a) is always
recommended as some patients have already made their CPR/DNR decision. Answer
choices c) and d) are both elements of effective, patient-centered DNR discussions, but
should occur after you have determined if CPR is medically indicated.
See Fast Fact #23, 24 DRN Discussion Part 1 and 2
