DNR / DNI Documentation for Cancer Patients in the ICU

1. Definitions and Scope

2. Why DNR/DNI Discussions Are Especially Relevant in Oncology ICU

• Cancer patients with metastatic burden, poor performance status, and limited organ reserve have significantly reduced CPR survival rates (overall ~5-20%; far lower in advanced malignancy)
• Treatment intent (curative vs. palliative) directly affects whether resuscitation aligns with patient goals
• Early and ongoing palliative care involvement reduces ICU length of stay and ICU deaths for cancer patients - Miller's Anesthesia, 10e
• The PREDICT score assigns 10 points each to both "ICU admission with multiorgan failure" and "current diagnosis of cancer" - a combined score of 20, which alone exceeds the threshold of >13 predicting 1-year mortality with 95% specificity - Tintinalli's Emergency Medicine
• A 2026 review in Current Oncology (PMID 42041721) emphasizes that proportionality between likely benefit and risk of prolonging suffering, attention to prognosis and neurological outcomes, and rigorous alignment with goals of care are all mandatory in oncology resuscitation decisions

3. Legal Document Framework

• Code status (full code, DNR, DNI, or comfort care only)
• Hospital transport preference
• Desire for intubation/mechanical ventilation
• IV fluids and artificial nutrition preferences
• Antibiotic use preferences
• Comfort measures

4. Required Documentation Elements in the ICU Chart

4a. The Conversation Note (Progress Note / Goals of Care Note)

1. Who was present - patient (if decisionally capable), surrogate/healthcare proxy, family members, palliative care team, chaplain if present
2. Decisional capacity assessment - explicitly state whether patient has capacity; if not, identify the legal surrogate decision-maker
3. Patient's understanding of diagnosis and prognosis - what the patient/family understands about the cancer, its extent, and likely trajectory
4. Goals of care framing - life prolongation vs. functional independence vs. comfort
5. Specific discussion of CPR - likelihood of success in the context of their cancer, risks (rib fractures, prolonged ICU time, neurological injury), realistic outcomes
6. Specific discussion of intubation - what it involves, implications for communication, likelihood of successful extubation given their cancer stage
7. Patient/surrogate decision reached - clearly state the agreed-upon code status
8. Plan communicated to team - nursing, respiratory therapy, on-call residents all notified

4b. The Medical Order

• Enter DNR/DNI as an active physician order in the electronic medical record (EMR)
• The order should specify exactly what is prohibited (CPR only, or CPR + intubation)
• Prominently flag in nursing care plan, EMR alerts, and bedside documentation per institutional policy
• Do not rely on verbal orders alone - written/electronic order is required

4c. Perioperative or Procedural Period

• DNR/DNI status must be explicitly re-discussed before the procedure
• Any temporary suspension of DNR/DNI during the procedure must be documented in the chart before the procedure begins
• After the procedure, the original order must be reinstated and documented
• The procedural team may not be familiar with prior discussions - do not assume they have reviewed advance directives

5. The Goals-of-Care Conversation Framework

"Ideally, the discussion about code status takes place in the context of a conversation about the patient's overall health and goals. For example, one patient might decide on life prolongation as a goal, in which case a physician might recommend resuscitation attempts even if unlikely to succeed, whereas another patient with the same illness might prioritize physical independence as a goal, in which case the physician might recommend a DNR order to decrease the likelihood of prolonged ICU time or an unacceptable physical status."

REMAP Mnemonic (for structuring the discussion)

Language Considerations

• "Allow natural death" (AND) has been studied as an alternative to "do not resuscitate" in terminal cancer patients - no clear evidence one term is preferred, but AND may be more emotionally acceptable to some patients and families
• Avoid framing as "withdrawing care" - reinforce what will continue to be done (symptom management, family presence, comfort)

6. Special Situations in Oncology ICU

Capacity and Surrogacy

• If the patient lacks capacity (encephalopathy, heavy sedation, delirium from cancer or its treatment), identify the legal healthcare surrogate immediately
• Document surrogate authority in the chart (healthcare proxy document, durable power of attorney, or state default hierarchy)
• Surrogate decisions should reflect the patient's previously expressed values and wishes, not the surrogate's own preferences

Pre-existing Advance Directive

• If the patient already has a living will, POLST, or prior DNR order: review, acknowledge it in documentation, and convert to an active inpatient medical order
• Do not assume a prior outpatient POLST automatically becomes an active ICU order - verify per institutional policy

DNR Reversal

• Studies show nearly half of patients with a prior DNR reverse the order upon a subsequent admission (e.g., readmission for sepsis or pneumonia)
• This is legally permissible - a patient with capacity can change code status at any time
• Any change must be documented with the same rigor as the original order, including the conversation note and an updated medical order

"DNR Does Not Mean Do Not Treat" - The Withholding Problem

• Retrospective studies confirm that physicians are more likely to withhold a wide spectrum of care (IV fluids, diagnostic studies, ICU transfer, bronchoscopy) from DNR/DNI patients compared to full code patients - independent of appropriateness
• This represents clinician value judgments, not medical rationale, and is a documented quality problem
• Documentation should explicitly state what treatments are to be continued and what the rationale is for any limitation beyond CPR/intubation

7. Interdisciplinary Team and Documentation Responsibilities

8. Key Documentation Checklist for Cancer ICU Patients

• Advance directive reviewed and acknowledged in chart
• Decisional capacity documented (or surrogate identified)
• Goals-of-care conversation note completed (with attendees listed)
• Prognosis discussion documented (cancer stage, performance status, expected trajectory)
• Explicit discussion of CPR and intubation documented
• Patient/surrogate decision documented
• Active DNR/DNI order entered in EMR
• Nursing care plan and bedside documentation updated
• POLST/MOLST completed if transitioning to post-acute or hospice
• Re-evaluation scheduled or triggered by change in clinical status
• Treatments to be continued explicitly listed (to prevent "do not treat" conflation)
• Perioperative DNR re-discussion documented if procedure planned