Unilateral do-not-resuscitate (DNR) orders, which are DNR orders placed by clinicians without consent of patients or surrogates, pose some unique ethical concerns. During the beginning of the COVID-19 pandemic, some clinicians had concerns about how these orders were being used.
“In talking with clinicians from multiple hospitals, there was concern unilateral DNR orders were being used disproportionately in certain populations,” says Gina Piscitello, MD, MS, clinical assistant professor and research fellow at the University of Pittsburgh School of Medicine. Piscitello and colleagues conducted a study to determine if the anecdotal observations were supported by data. The researchers analyzed a retrospective cross-sectional study of unilateral DNR use for 1,473 ICU patients from April 2020 to April 2021 at two academic medical centers in the Chicago metropolitan area.1 Clinicians placed DNR orders for 41% of the patients and unilateral DNR orders for 3% of the patients. Clinicians placed a disproportionately higher rate of unilateral DNR orders for Spanish-speaking patients, even after controlling for severity of illness. “This finding is concerning, given that unilateral DNR orders override a patient’s autonomy to make decisions about whether they receive CPR,” says Piscitello. The ethical concern is that clinicians are more likely to override patient autonomy for some patients when compared to others. “This can contribute to negative effects, such as worsening trust between clinicians, patients, and surrogates,” says Piscitello.
Ethicists were not involved in the majority of cases where unilateral DNR orders were placed. Clinicians had clear guidelines to use these orders only if the patient met criteria for physiologic futility, where the patient was on maximum life support and experienced a cardiac arrest from a known cause that cannot be reversed. Piscitello says it is unlikely that ethics consults on individual cases where unilateral DNR orders were placed would have changed the disparities that were observed. Those patients did meet criteria for use of the orders. “Ethics could be helpful by retrospectively reviewing in which patients these orders are placed, and helping to evaluate why these disparities exist and aid in determining how to reduce these disparities,” Piscitello offers.
- Piscitello GM, Tyker A, Schenker Y, et al. Disparities in unilateral do not resuscitate order use during the COVID-19 pandemic. Crit Care Med 2023;51:1012-1022.
