DNR, Withdrawing Treatment and Goals of Care

Code Status Clarification and Goals of Care

In the critical care setting, clear communication regarding resuscitation preferences is foundational. A Do Not Resuscitate (DNR) order specifically directs clinicians not to perform cardiopulmonary resuscitation (CPR) during a cardiac arrest. This limitation includes chest compressions, resuscitative defibrillation, and airway interventions undertaken as part of CPR. However, a DNR order does not restrict intensive medical interventions, such as vasoactive infusions, blood products, or renal replacement therapy, prior to an actual arrest unless explicitly stated. Clinicians must recognize that limitations on intubation for acute respiratory failure prior to cardiac arrest require separate clarification. Allow Natural Death (AND) is an alternative term for a DNR order that emphasizes a natural dying process, but it does not by itself establish a comfort-only plan of care.

Establishing code status is an ongoing clinical responsibility. The critical care team should clarify code status and goals of care upon admission and revisit them whenever the patient's condition, prognosis, or preferences change significantly. If no applicable resuscitation-limiting order or legally recognized patient or surrogate instruction is in place, the critical care team must initiate resuscitation while promptly clarifying the patient's wishes under applicable law and policy. Code status is also not static across clinical transitions; before a procedure requiring anesthesia, an existing DNR order must undergo required reconsideration with the patient or authorized surrogate rather than being automatically suspended.

Goals of care conversations frequently address treatments that clinicians find ethically challenging. Critical care consensus favors the term 'potentially inappropriate treatment' when an intervention may achieve an intended physiological effect, but clinicians question whether providing it is ethically appropriate due to competing ethical considerations. In contrast, 'physiologically futile treatment' refers specifically to an intervention that cannot achieve its intended physiological goal. Differentiating these concepts helps teams navigate complex decisions without mischaracterizing clinical realities.