DNR or no DNR

[Zakariya Al-Salam]

Dear colleagues,

More and more units are adopting policies and procedures related to DNR and Companionate Care. These policies and procedures, usually, depend on many factors the least of which is the scientific evidence. I personally called them consensus-based policies rather than Clinical Practice Guidelines. Having said that I still followed them and in case I believe the situation in front of me does not relate well to the policy, I write justifications and discuss the issue with other member of the team.

Now, allow me to give you a brief scenario and please let me know your opinion.

You are doing the round in one of the weekends and you are faced with twins who were born 2 days ago at 23 weeks' gestation (b.wt: 540 and 630 g). They required intubation and given standard care of any premature.

Twin 1
on HFO very high settings and 100 oxygen and iNO, hypertensive on triple inotropes, hypoxic and pH: 6.8. He has also renal failure, anemic and DIC. He is not responsive to the standard therapy you are providing.

Many of you probably believe this baby is in terminal stage and DNR and compassionate care ordered should be written after counseling the parents. Since it is weekend you are the only consultant available and there is no one else with you to counter sign DNR form. Using your clinical judgment do you believe it is right to say this patient is not responsive and if patient gets worse there is nothing we can do about it. OR you are still going to do CPR?

I am looking forward hearing from you

Best regards,

Zakariya Al-Salam

[Stefan Johansson]

Very interesting question.
I have often felt about "Do Not Resuscitate"-decisions in two different ways. Usually, one senses the situation correctly from the clinical scenario and "by gut-feeling". On the other hand, I have personally often felt that there's a lack of official policy on the decision-making process.

I think one could decide upon a "work-flow"; how care and the infant's condition is assessed in the team; 2nd opinions from another consultant; parental involvement etc-etc. Some would argue that those steps are difficult to write down on a paper, but I would argue that it is a strength for a department to have these steps defined. We all need to consider certain aspects before we can consider treatment to be futile, so why not put this work-flow into words. A defined decision-making process would also be beneficial in contacts with parents, and give care a higher degree of transparency. "This is how we these decisions are formed".

In the scenario you describe, I think one needs to consider the suffering of the individual infant. Although this is a hypothetical situation (and I know nothing about the legal aspects of the DNR form you have); if care seems futile and the infant is suffering this would be more important for me than not having the form counter-signed. For myself, I think papers are important, but the suffering of patients comes first.

PS. A similar topic was discussed here: http://www.99nicu.org/forum/showthread.php?t=46

[urai06]

Dear sir,
I would like to share our experience about this case.I agree with Dr Stefan that you should discuss with parents about their baby condition .In this condition we give all medications to the baby.If he is not respose,they should accept not do anything more.I am puzzle about using iNo in this baby.In our country we cannot supportiNo in preterm like this because we usually use in term with severe respiratory failure with PPHN that not response to the other medications.I would like to ask dr Stefan about iNO in preterm.
Urai06

[Zakariya Al-Salam]

Thanks for the reply.

You know, giving standard care for premature infants means lots of things; one of them is to talk with parents and keeping them updated about the situation of their baby.

With all due respect, discussing whether or not to give iNO is a diversion from the main isssue. We can discuss that in the respiratory section.

Now, allow me to make it more to the point. You have an extremely premature infant with a very high mortality and poor prognosis. He is on full cardio-respiratory support and going to arrest any moment. You have nobody to coutersign the DNR form (you need 3 consultants). It is a weekend. Do you offer CRP if the baby actually arrested?

Thanks
Zakariya

[Stefan Johansson]

I would not.

[urai06]

I would not too.
Urai06

[Zakariya Al-Salam]

Thanks a lot. I agree with you.

Allow me to share with one thought. I believe CPR in the form of chest compressions is a very basic intervention aimed to pump blood to vital organs mainly the brain. It is a measure used before advanced care can be provided and be effective. Once patient is on full cardiopulmonary support (according to the standard) and arrested then I am not really sure adding chest compressions or some more epinephrine would do anything beneficial to the patient.

Once again thanks for the reply and looking forward more participation to the forum.

[rehman_naveed]

I also agree with the above comments. In our unit if baby is already on high doses of epinephrine, dopamine and dobutamine and has poor outcome, we dont give epinephrine during chest compression as giving epi during resuscitation will not add benefit to already continous infusion of epinephrine. and truely speaking CPR will not be fruitful.
Thanks