The Nursing Home Call with a DNR in the Drawer
You are an EMT responding to a nursing home for an 86-year-old woman with advanced dementia and a recent stroke. Staff report she has been 'not herself' for two days, with reduced oral intake and a low-grade fever. On arrival she is drowsy but rousable, GCS 13 (E3 V4 M6), RR 24, SpO2 89% on room air, HR 102, BP 104/62, temperature 37.9 °C. She has crackles at the right base. The nurse hands you a folder containing a valid, signed, and witnessed Do Not Attempt Resuscitation (DNAR) order and a healthcare proxy form naming her daughter, who is not present and cannot be reached. The family has previously told staff she 'would not want to be kept going on machines'. The GP is unavailable. The nearest ED is 20 minutes away.
1. Does the DNAR order prevent you from treating this patient? Explain what the DNAR does and does not cover, and how it interacts with your treatment plan.
Read the worked answer
No - a DNAR does not prevent treatment. A DNAR order specifically addresses cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. It does not authorise withholding of other appropriate treatment such as oxygen, antibiotics, fluids, or comfort care.
What it means here:
- If she arrests, you do not commence CPR or defibrillation, consistent with the valid order.
- While she is alive, you treat reversible problems: oxygen for SpO2 89% (titrate to 94–98%), position for comfort, monitor, and consider IV/SC fluids if she is dehydrated and this is consistent with her goals of care.
- The order must be valid - signed, witnessed, and clearly identifying the patient. Confirm the name and date match.
- Document that you saw the DNAR and acted on it.
The trap: treating a DNAR as a 'do not treat' order is wrong and is a common exam error.
2. The daughter cannot be reached. How do you decide whether to transport, and what factors guide a 'comfort-focused' versus 'hospital transfer' plan?
Read the worked answer
This is a goals-of-care decision made with the information available:
Factors supporting comfort-focused care at the facility:
- Advanced dementia and recent stroke - limited reversibility of her underlying condition.
- Documented family statement that she 'would not want to be kept going on machines'.
- A valid DNAR consistent with that stated wish.
- A likely aspiration pneumonia (crackles, fever, reduced intake) in a patient with advanced dementia - a condition with high mortality and where hospital transfer often does not change outcome.
Factors supporting transfer:
- She is rousable and not in arrest; hypoxia and possible sepsis are treatable, and antibiotics and fluids may improve comfort.
- The proxy is unreachable - you cannot confirm the current wish, and the safest default is to treat reversible problems rather than let her deteriorate untreated.
Balanced approach:
- Give oxygen, position, monitor, and contact the facility GP/out-of-hours service for antibiotics and fluids if possible.
- If she is deteriorating (falling GCS, rising RR, hypoxia not corrected), transfer to ED for assessment - the DNAR still applies in the event of arrest, and the ED can clarify goals with the proxy.
- Do not initiate CPR if she arrests en route, per the valid order.
- Document the reasoning, the attempts to contact the proxy, and the plan.
The exam point: the absence of a reachable proxy does not automatically mean 'do nothing' or 'do everything' - you treat what is reversible while respecting the documented wish.