A case series of patients who were do not resuscitate but underwent cardiopulmonary resuscitation

Some patients wish to forgo cardiopulmonary resuscitation (CPR) should they have a cardiac arrest. Unfortunately, there have been instances of CPR being performed despite a documented decision of do-not-resuscitate (DNR),^,  but few studies have discussed why this occurs.

A retrospective chart review was completed on all adult patients who had a cardiac arrest with CPR done between January 2012 and December 2018 at the Minneapolis Veteran Affairs Health Care System. A total of 327 patients underwent CPR during that timeframe. Nine (2.8%) were identified as undesired administration of CPR (Table 1). Seven (78%) patients had return of spontaneous circulation (ROSC), but only 3 (43%) survived more than 24 h post resuscitation.

Case 1: Cardiac arrest occurred after tracheostomy dislodgement, CPR started despite treatment team’s awareness of DNR status.

Case 2: Patient elected to remain DNR when discussed prior to procedure. Cardiac arrest occurred after moderate conscious sedation administered and CPR started.

Case 3: Patient brought in by paramedics and cardiac arrest occurred. CPR started, but stopped after Physician’s Order for Life Sustaining Treatment (POLST) was found in the ambulance.

Cases 4–9: The remaining cases of cardiac arrest occurred in the inpatient setting, with the responding provider unaware of the patient’s DNR status. Five of these cases had a documented DNR order in the chart, while in the remaining case it had not yet been ordered. In three of the cases, DNR status was discovered during course of CPR and compressions were terminated.

In our study, factors that contributed to undesired CPR include: physicians overriding code status, failure to effectively disseminate and honor advanced directives, and unawareness of a patient’s code status. Cases 1 and 2 describe instances where physicians attempted resuscitation despite previously discussed DNR wishes. This may occur if physicians believe the arrest was due to physician error or procedural complication, and not all potential scenarios can be discussed. A survey found that 29% of physicians “certainly would” override a DNR order in the case of a complication leading to cardiac arrest and 69% would in the case of a physician error. Even if a resuscitation is thought likely to be successful, seeking to correct the error can lead to further interventions and harms without the ability of the patient to provide informed consent. Another reason patients receive undesired CPR is unawareness or feeling uncomfortable honoring life sustaining treatment decisions made through outpatient documents (advance directive or POLST). Moreover, POLST or advanced directives may not always accompany patients. Several of our cases illustrate examples of undesired CPR due to unawareness of patient’s DNR status. This mistake can occur given the multiple hand-offs each day between different teams of medical staff and often the resuscitation team is not familiar with the patient. Studies have found more than a 10 % discordance between an ordered code status and sign-out documentation and between patient reported and physician ordered resuscitation preference.^,  More studies are needed to devise better methods of communicating code status at the bedside in a discrete but quickly accessible manner.