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Letter| Volume 49, ISSUE 6, e2-e4, June 2015

Do-Not-Resuscitate (DNR) Orders and Consultants' Willingness to Perform Invasive Procedures

Open AccessPublished:March 28, 2015DOI:https://doi.org/10.1016/j.jpainsymman.2015.03.003
      To the Editor:
      As disease progresses and palliation becomes the goal of care, treatment ideally maximizes symptom control and empowers patients and families to make important end-of-life decisions. Most patients with terminal illness prefer to die in their own homes,
      • Teno J.M.
      • Casey V.A.
      • Welch L.C.
      • Edgman-Levitan S.
      Patient-focused, family-centered end-of-life medical care: views of the guidelines and bereaved family members.
      usually under hospice care, and the quality of home death is rated higher than hospital death.
      • Hales S.
      • Chiu A.
      • Husain A.
      • et al.
      The quality of dying and death in cancer and its relationship to palliative care and place of death.
      Do-not-resuscitate (DNR) orders are frequently discussed with patients and/or their family members to avoid invasive interventions such as cardiopulmonary resuscitation or intubation, which usually result in poor outcomes for patients with advanced cancer.
      • Garrido M.M.
      • Balboni T.A.
      • Maciejewski P.K.
      • Bao Y.
      • Prigerson H.G.
      Quality of life and cost of care at the end of life: the role of advance directives.
      However, sometimes invasive procedures are required to manage severe symptoms. We report the case of a woman with advanced cancer who needed a chest tube insertion to relieve severe dyspnea from a pneumothorax; the consultant was hesitant to perform this procedure because the patient had a DNR order.

      Case

      A woman in her mid-40s with metastatic breast carcinoma to the pleura, mediastinum, lymph nodes, and bone was admitted to our hospital with shortness of breath. She was first diagnosed 11 years earlier, and after initial response to several therapies (surgery, radiation, and chemotherapy), her disease recurred. She then received several different chemotherapy regimens. The last cycle of chemotherapy was completed two weeks before she was admitted to the breast medical oncology service of our hospital for shortness of breath.
      The palliative care service was consulted to help with symptom management and end-of-life care. At the time of initial evaluation, the patient reported being very short of breath and anxious; she also said that she had been unable to sleep (during the previous weeks, she had slept in a chair because of the dyspnea). She had chest wall pain on the left side and constipation. According to the Edmonton Symptom Assessment System (ESAS) scale,
      • Bruera E.
      • Kuehn N.
      • Miller M.J.
      • Selmser P.
      • Macmillan K.
      The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients.
      where 10 represents the worst possible outcome, the patient scored 10 for dyspnea, 7 for sleep, 6 for anxiety, 6 for well-being, 5 for fatigue and appetite, and 4 for pain and depression.
      On physical examination, the patient was obese, afebrile, and in acute respiratory distress. Her vital signs revealed tachycardia (110 beats/minute), a respiratory rate of 22, and normal blood pressure and temperature. She was on 100% oxygen supplementation to keep her oxygen saturation level above 90%. The physical examination was unremarkable apart from occasional rhonchi, bilateral fine crackles, bilateral hypoventilation (which was more marked on the left side), and moderate edema in her legs.
      The patient expressed her desire to be at home so that she could enjoy her last days with her family. However, because of her persistent dyspnea, hypoxia, and severe anxiety, her only option was discharge to an inpatient hospice care facility. Our psychosocial team provided emotional support to the patient and her family. Goals of care were discussed with the primary team and then with the patient and her family. She agreed to a DNR order.
      The patient was transferred to the acute palliative care unit (APCU), with the goal of controlling her symptoms and weaning her off oxygen. She was started on patient-controlled analgesia with hydromorphone, nebulized fentanyl (25 μg) every six hours, and intravenous dexamethasone (4 mg) twice daily to control the dyspnea; the patient took haloperidol and lorazepam as needed for anxiety and/or agitation.
      During the first 48 hours, the patient's symptoms improved: she scored 6 for dyspnea; 4 for fatigue, appetite, sleep, and well-being; and 2 for anxiety on the ESAS. Her requirement for oxygen decreased to 70% to keep her oxygen saturation level above 90%. She was able to walk with physical therapy assistance.
      On the third day in the APCU, the patient developed a sudden episode of severe dyspnea, with moderate to severe anxiety, diaphoresis, and hypoxia; the oxygen concentration was increased to 100% to keep her oxygen saturation level above 90%. An emergent portable chest roentgenogram showed the presence of a left-sided tension hydropneumothorax. The pulmonary service was consulted emergently. The pulmonologist was hesitant to perform a chest tube thoracostomy, given the patient's DNR status. It was clarified to the pulmonologist that the only other available palliative option, in the absence of a chest tube, was to sedate the patient. After discussing the situation with the patient and her family, the pulmonary team decided to perform a chest thoracostomy with a Heimlich valve. The patient underwent the procedure without complication, and her symptoms improved. The chest tube drained a purulent material, with culture revealing alpha-hemolytic streptococci sensitive to quinolones. The patient was started on levofloxacin. Over the next 72 hours, the patient improved markedly, she was able to tolerate the nasal cannula, and her oxygen was weaned to 4 L by nasal cannula. The chest tube was connected to a mobile chest drain without complication. She was able to participate in occupational and physical therapy activities. Our psychosocial team continued to provide support for the patient and her family. The patient was discharged to home with hospice care and lived for about three months. During this time, the patient had one episode of tube malfunction, which was addressed by the pulmonary team in an outpatient center.

      Comment

      This case highlights some of the challenges faced by patients and palliative care clinicians in the hospital setting and illustrates the perception of the meaning of DNR orders in patients with advanced cancer. The patient's goals were clear: she wanted to spend the remainder of her life at home. She understood the terminal nature of her cancer, and she did not want cardiopulmonary resuscitation if her heart stopped. However, she did want to receive all other supportive measures to relieve her symptoms and help her discharge to home.
      After she developed a pneumothorax, there were two main options: chest thoracostomy or palliative sedation.
      • Beller E.M.
      • van Driel M.L.
      • McGregor L.
      • Truong S.
      • Mitchell G.
      Palliative pharmacological sedation for terminally ill adults.
      However, worsening of dyspnea because of the pneumothorax was not refractory, and therefore, did not qualify for palliative sedation. A refractory symptom is one that is unresponsive to multiple available palliative interventions, which is different from this case.
      • Cherny N.I.
      Sedation for the care of patients with advanced cancer.
      The pulmonologist's hesitation to perform a chest tube thoracostomy is understandable, given the possible surgical complications. A recent study of patients who underwent emergency vascular surgery found that DNR orders were independently associated with increased 30-day mortality, graft failure, and failure to wean from mechanical ventilation.
      • Aziz H.
      • Branco B.C.
      • Braun J.
      • et al.
      The influence of do-not-resuscitate status on the outcomes of patients undergoing emergency vascular operations.
      However, the palliative care team could only provide sedation as an alternative to the chest tube thoracostomy, as increasing the opioid dose was not controlling the patient's symptoms.
      Our patient achieved her goal of going home and she lived for about three months after her discharge from the hospital. The thoracostomy procedure was critical in improving her symptoms and allowing her home discharge. Without it, premature sedation until death was the only available option. This time she spent at home under hospice care was essential for the patient and her family members in receiving good end-of-life care.
      In conclusion, decisions at the end of life are complex and should be individualized. The presence of a DNR order should not prevent patients from receiving needed medical therapy including invasive procedures if consistent with the patient's wishes. Consultants are not always familiar with available palliative care options, and candid discussion about available therapeutic options, empowering patients and their families to participate in decisions while balancing the benefits and risks of treatments, is essential at the end of life. As early palliative care could be associated with prolonged survival,
      • Temel J.S.
      • Greer J.A.
      • Muzikansky A.
      • et al.
      Early palliative care for patients with metastatic non-small-cell lung cancer.
      good palliative care at the end of life could be associated with longer survival and prevent premature sedation.

      References

        • Teno J.M.
        • Casey V.A.
        • Welch L.C.
        • Edgman-Levitan S.
        Patient-focused, family-centered end-of-life medical care: views of the guidelines and bereaved family members.
        J Pain Symptom Manage. 2001; 22: 738-751
        • Hales S.
        • Chiu A.
        • Husain A.
        • et al.
        The quality of dying and death in cancer and its relationship to palliative care and place of death.
        J Pain Symptom Manage. 2014; 48: 839-851
        • Garrido M.M.
        • Balboni T.A.
        • Maciejewski P.K.
        • Bao Y.
        • Prigerson H.G.
        Quality of life and cost of care at the end of life: the role of advance directives.
        J Pain Symptom Manage. 2015; 49: 828-835
        • Bruera E.
        • Kuehn N.
        • Miller M.J.
        • Selmser P.
        • Macmillan K.
        The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients.
        J Palliat Care. 1991; 7: 6-9
        • Beller E.M.
        • van Driel M.L.
        • McGregor L.
        • Truong S.
        • Mitchell G.
        Palliative pharmacological sedation for terminally ill adults.
        Cochrane Database Syst Rev. 2015; : CD010206
        • Cherny N.I.
        Sedation for the care of patients with advanced cancer.
        Nat Clin Pract Oncol. 2006; 3: 492-500
        • Aziz H.
        • Branco B.C.
        • Braun J.
        • et al.
        The influence of do-not-resuscitate status on the outcomes of patients undergoing emergency vascular operations.
        J Vasc Surg. 2015;
        • Temel J.S.
        • Greer J.A.
        • Muzikansky A.
        • et al.
        Early palliative care for patients with metastatic non-small-cell lung cancer.
        N Engl J Med. 2010; 363: 733-742