What options are available to the patient and clinician in order to more fully define a patient’s DNR wishes?

What options are available to the patient and clinician in order to more fully define a patient’s DNR wishes?

The following are four choices for informed consent for DNR. The patient should be asked to choose an option and sign the consent.

·  Option 1: full resuscitation. This option assures the patient that no efforts will be overlooked or spared in order to assist with full resuscitative efforts. It is not inappropriate for a patient to revoke the DNR for the operative setting. This option works well for patients who will accept any intervention in exchange for the possibility of benefit.

·  Option 2: limited resuscitation, procedure-directed. Patients select which interventions they accept and reject. This works well for the patient who wants com-plete control over what procedures they will receive. However, it does not allow for the “clinical license” of the physician to interpret wishes when the patient’s desires may be ambiguous or inconsistent with clinical conditions.

·  Option 3: limited resuscitation, goal-directed (tempo-rary and reversible). This allows the physician to make a clinical judgment that the adverse clinical events present are both temporary AND reversible. If this is the case, then interventions to temporize the patient during the adverse event are acceptable to the patient. An example of this could be the need to intubate the trachea of a patient undergoing general anesthesia for surgery which is planned and elective.

·           Option 4: limited resuscitation, goal-directed (patient’s wishes known). This option allows the physician to make a clinical judgment to treat a patient based upon the known preferences and goals of the patient. This option is ideal in that it allows decision-making to take place based upon outcomes, rather than procedures. It is not necessarily contingent upon the outcome of the events being obviously temporary and reversible. Rather it allows a physician to make a decision about the care of a patient after that patient communicates a desired out-come. This is a more ambiguous statement for the patient but is more consistent with the practice of medicine, in which clinical situations are very dynamic. An example of this might be the case of an arterial injection of local anesthetic resulting in a grand mal seizure. The outcome of the grand mal seizure is not known, yet the physician knows that the event was accidental, the event is unre-lated to the reason that the patient has elected to be “DNR”, and the symptoms are treatable. In this case, the physician may elect to control the airway and intubate the trachea until the outcome is known.