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A patient with a history of metastatic bronchial carcinoma and end stage heart disease was admitted to hospital, after an accidental fall, because of epistaxis requiring nasal tamponade and blood transfusions. On day 2 the patient suffered from acute dyspnoea and finally respiratory and cardiac arrest. The patient was successfully resuscitated despite a do not resuscitate order (DNR order). A bolus aspiration of the nasal tamponade’s gauze was discovered as the reason for the arrest. This case report underlines the ethical dilemma in patients with an otherwise undisputed DNR order when the arrest is: (1) easy to resolve but not easy to detect; (2) iatrogenic in nature; and (3) is occurring in an unmonitored area (for example, the ward) as compared with an arrest in a well monitored area (for example, the intensive care unit and operating room).
This case report refers to several issues surrounding the difficult subject of do not resuscitate orders (DNR orders) and in-hospital resuscitation, especially when the life threatening situation is not caused by expected complications (that is, due to acute deterioration of underlying diseases) but is related to rare and sometimes trifling causes. Furthermore, our case report also emphasises the dilemma of DNR orders in the presence of iatrogenic complications.
A 75-year-old male patient was admitted to hospital after an accidental fall. On admission he suffered a severe nasal haemorrhage (while under oral anticoagulation) due to a fracture of the nasal bone. A computed tomography (CT) scan of the head showed a minimal subdural haematoma. There were no other injuries.
The patient’s medical history consisted of a bronchial carcinoma for which he underwent bilateral lobectomy 5 years ago. Last year he underwent palliative radiation as he had developed soft tissue metastases of the trachea. A chest x-ray 1 month ago revealed several new bilateral nodules that the patient did not want to be further explored. Other diseases the patient had included chronic obstructive pulmonary disease GOLD III, chronic renal insufficiency with a creatinine clearance of 20 ml/min, and an end stage hypertensive and valvular heart disease with recurrent decompensations, the last one leading to hospitalisation only 1 month ago. Echocardiography at that time showed a moderate aortic valve stenosis, a left ventricular ejection fraction of 25% (without relevant mitral regurgitation), and a pulmonary hypertension of 58 mm Hg with signs of cor pulmonale. Due to concomitant atrial fibrillation the patient was orally anticoagulated.
Laboratory testing on admission showed a haemoglobin value of 59 g/l and an international normalised ratio (INR) of 2.2. The serum creatinine and urea values were 250 μmol/l and 17.5 mg/dl, respectively. Other studies were in the normal range. The patient was admitted to the intensive care unit (ICU) for surveillance and further medical care. He needed transfusion of four units of packed red cells and six units of fresh frozen plasma to convert oral anticoagulation. A nasal tamponade with gauze was installed which had to be changed on the same day due to persistent bleeding.
During the previous hospital stay relevant issues concerning resuscitation had been discussed in great detail and, in accordance with the patient’s preferences, a DNR order was established. In the absence of relevant changes to it, the DNR order was maintained for the current hospital stay also.
The clinical course during the stay in the ICU was uneventful and it was possible to transfer the patient to the ward on day 2. On the same day the patient developed acute dyspnoea and a decrease in oxygen saturation. The first suspicion was pulmonary embolism due to discontinued anticoagulation. The patient was transferred to the radiology department under anaesthesia standby for an emergency thoracic CT scan. Just before the examination could be done the patient deteriorated, the dyspnoea worsened, his oxygen saturation dropped, he became bradycardic and finally asystolic. As the anaesthetist was unaware of the DNR order, cardiopulmonary resuscitation (CPR) was started and the patient was intubated for mechanical ventilation. Immediately after intubation the patient’s haemodynamic and pulmonary status stabilised. The CT scan excluded pulmonary embolism. The patient was transferred to the ICU. Repeated ECG and blood samples for cardiac enzymes remained normal. Later we received information from the anaesthetist that, during the resuscitation, gauze had been removed from the epiglottis and, in view of this, aspiration of the nasal tamponade was considered as the cause for respiratory deterioration followed by cardiac arrest. The patient was successfully extubated 4 h after the event and a subsequent clinical examination did not reveal any signs of neurological deficiencies. The further clinical course was uneventful. The patient was discharged from hospital 10 days later and is still alive 1 year on. As stated by the patient, there were no changes in his quality of life after resuscitation. He also confirmed that, despite the DNR order, he has no regrets about the resuscitation, although he still prefers to have a DNR order for the future.
This case report raises several issues on the difficult subject of DNR orders and in-hospital resuscitation, especially when the life threatening situation is not caused by expected complications (for example, due to acute deterioration of underlying diseases) but is related to rare and sometimes trifling causes. Furthermore, our case report also emphasises the dilemma of DNR orders in the presence of iatrogenic complications.
A recent review1 reported an incidence of in-hospital cardiopulmonary arrests of 1–5 arrests per 1000 patient admissions, and therefore resuscitation efforts are routinely performed in hospitals. Outcome can be determined by: (1) an immediate survival with a return of spontaneous circulation as direct success of the cardiopulmonary resuscitation manoeuvres; and (2) the more important survival to discharge as many patients die during the first 24 h after an initially successful resuscitation. The most commonly quoted outcome is the survival to discharge, which varies from 0–42%, with the most common range in the major studies of approximately 20%.
There are several conditions in different groups of patients that decrease the rate of survival to discharge to virtually nil in some cases.2 These are conditions such as sepsis on the day before resuscitation, metastatic cancer, dementia or a serum creatinine value at a cut-point of 1.5 mg/dl (130 μmol/l). Another important predictor of survival is the type of arrest, with highest rates of survival to discharge after primary respiratory arrest and lowest after pulseless electrical activity or asystole.3 On the other hand, improved survival rates after resuscitation are observed for witnessed cardiac arrests.
There are, of course, some patients with cardiopulmonary arrest in whom resuscitation should not be performed—that is, where a DNR order has been written. The basis for such decisions is given by the main ethical principles that comprise beneficence, non-maleficence, justice and autonomy.4 As these ethical principles also apply to resuscitation issues, DNR orders should be considered in patients who object to CPR due to comprehensible reasons or in patients in whom a CPR would be futile due to medical considerations. In a prospective cohort study on the factors associated with DNR orders, the writing of them was mainly influenced by the patients’ preferences followed by the probability of surviving the next 2 months.5 Another interesting finding of this study was the fact that only 52% of patients who preferred not to be resuscitated actually had a written DNR order. With respect to good clinical practice, therefore, it must become a front ranking task to improve that number urgently. Beyond that, awareness of the DNR orders in the clinical background also has to be notably improved. For example, in radiology departments the compliance with DNR orders is low.6 Twenty per cent of respondents to a questionnaire sent to hospital based radiology departments would resuscitate patients with DNR orders, and 38% had resuscitated patients with DNR orders in the past. Reasons for performing CPR in patients with DNR orders were, among others, unawareness of the DNR status. This was also the case in our patient with a written DNR order, where anaesthetic standby was ordered for the diagnostic CT scan and, even more controversially, where resuscitation was actually performed.
In several clinical situations, a pre-existing DNR order can be reconsidered and discussed. Following the main ethical principles mentioned before, this should be limited to situations where the decision for the DNR order is exclusively based on medical considerations—that is, where CRP is expected to be futile due to the underlying diseases and cardiopulmonary arrest occurs under special conditions (such as in the operating room, etc) with demonstrable improved rates of successful resuscitations. In fact, DNR orders have been routinely suspended in patients undergoing surgery during the intraoperative and immediate postoperative period.7–9 Another situation where discussions about overriding DNR orders occurs is in cardiopulmonary arrest during haemodialysis, as these arrests are witnessed and frequently triggered by iatrogenic causes.10
Iatrogenic complications occur as an adverse reaction to treatment or as a failure to treat. In hospitalised patients 14% of cardiac arrests follow an iatrogenic complication that are mainly medication errors and toxic effects (44%), or suboptimal response by physicians to clinical signs and symptoms (28%).11 Patients with an iatrogenic cardiac arrest were more likely to survive to discharge. There is no consensus in the literature about how to deal with iatrogenic cardiopulmonary arrests in DNR patients. Some authors state that they will perform resuscitation only if there is reason to believe that it may be consistent with the patient’s intention.10,12,13 Others feel that there are situations where resuscitating a patient in an iatrogenic arrest can be medically and ethically justified.12 In a survey with three different hypothetical case scenarios, physicians were unlikely to override a DNR order in patients suffering from a cardiac arrest originating from the underlying disease.13 In patients who arrest due to a complication of medical treatment, however, physicians were much more likely to resuscitate and even more physicians would resuscitate a patient whose arrest was caused by a physician’s error. A “limited aggressive therapy order” has been discussed for patients with a DNR order in situations with a likelihood of “higher success”, such as witnessed cardiopulmonary arrests with ventricular fibrillation or tachycardia as initial rhythm, an arrest in the operating room, or a cardiac arrest due to an easily identifiable iatrogenic cause.14
If, however, the DNR order is due to the patient’s declared intention and/or due to ethical considerations, the authors of this report clearly disclaim suspension of DNR orders irrespective of the current situation—for example, whether the arrest occurs during surgery, ICU stay, and haemodialysis, or even if the cause for the cardiopulmonary arrest is an iatrogenic one (always under the assumption that the medical action that had triggered the arrest was free of any malicious intention). In doing so, however, this by no means excludes taking the greatest efforts to correct for triggering causes and mistakes, but any such efforts have to be below the threshold of CPR—that is, intubation/mechanical ventilation (unless already preinstalled) and cardiac massage. In case the arrest is due to ventricular fibrillation and occurs in the operating room, an attempt at electrical defibrillation might be justified. In daily practice, however, suspension of DNR orders is often managed in a different (albeit less differentiated) way.
In our patient, cardiopulmonary arrest was not related to his advanced stage of comorbidities but brought on by an unexpected bagatelle—that is, a bolus aspiration of the gauze from the nasal tamponade. During CPR, the obstacle was easily removed, resulting in a successful resuscitation without sustained harm. Unexpected and/or easy to resolve conditions could scarcely be excluded as a potential cause of cardiopulmonary arrest, and thus may give rise to neglect by principle DNR orders due to medical considerations in nearly all—except some very specific—situations. Well understood, such considerations are independent of the circumstance whether the life threatening complication is iatrogenic in nature or not. With respect to similar cases, and knowing about successful resuscitations also in patients with apparently futile medical comorbidities, we would strongly encourage neglecting DNR orders that have been written exclusively due to medical considerations or, even more consistently, to desist from DNR orders if triggered by circumstances other than ethical considerations and/or the patient’s comprehensible will.
To sum up our personal recommendations concerning DNR orders, we would strongly encourage checking the patient’s intention concerning CPR on a routine basis—for example, at hospital admission. In case there are ethical considerations against CPR and/or the patient refuses possible CPR on a comprehensible basis, then a DNR order should be followed under any circumstances, independent of whether the arrest occurs during surgery or is due to an iatrogenic cause. By contrast, we would disclaim DNR orders that are triggered exclusively due to medical considerations—that is, in patients with advanced stage comorbidities in whom CRP is expected to be unsuccessful and/or might result in harm. We would definitely encourage the initiation of CPR in such patients, but would terminate such endeavours early if the patient was unresponsive.
In the case of our patient, the arrest was due to an iatrogenic cause which was easily resolved, and thus the CPR was successful and by no means regretted by the patient. Nevertheless, the patient still prefers having a DNR order for the future.
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.