Does the DNR Patient Belong in the ICU?

Abstract

A small but significant percentage of ICU patients are designated DNR at some time during their ICU stay. DNR patients in the ICU are more ill, use more resources (including nursing care) and have a higher mortality rate than non-DNR patients. In an age of a critical care nursing shortage, spiraling health costs, and an emphasis on the just allocation and use of scarce resources, the question whether DNR patients should be excluded from the ICU is appropriately raised. After examination, a model policy to exclude DNR patients from the ICU was rejected because a policy excluding DNR patients from the ICU would have adverse effects on patient autonomy, beneficence, the nurse-patient relationship and fidelity, and the practice of writing DNR orders. Furthermore, such a policy would not resolve triage problems. DNR patients can appropriately be given curative or palliative treatment in an ICU when their treatment goals are reasonable and the treatment can only be given in the ICU. Conversely, DNR patients do not belong in the ICU when their treatment goals are inappropriate or when their treatment could be received on another unit. "Appropriate" and "inappropriate" treatment was not thoroughly examined except to define them in relation to Young's "point Z," the theoretical point on a life-death continuum at which one stops prolonging life and instead prolongs death. In this authors' opinion, beyond point Z, only palliative treatment is justified in the ICU. DNR patients beyond point Z should not receive curative treatments in the ICU. Many DNR patients fitting this description remain in ICUs, however, perhaps because of physician reluctance to withdraw or withhold life-sustaining treatments.(ABSTRACT TRUNCATED AT 250 WORDS)