B103-02 Unilateral Do-Not-Resuscitate (UDNR) Orders: A Case Series in Ethical and Clinical Decision-Making

A unilateral do-not-resuscitate (UDNR) order is a directive to withhold cardiopulmonary resuscitation (CPR) without informed consent of the surrogate decision-maker (SDM). It is typically reserved when CPR is considered medically futile to uphold non-maleficence and relieve moral distress. We present two cases in which UDNR orders were instituted in critically ill patients. These cases highlight the clinical and ethical complexities involved when balancing autonomy and non-maleficence. Case 1: 61-year-old female with metastatic pancreatic cancer complicated by biliary and ureteral obstruction, was admitted to the ICU for recurrent aspiration, failure to thrive, intolerance of feeds, bleeding, and shock. Patient was deemed an unsuitable candidate for further cancer-directed therapy or surgical intervention. Case 2: 35-year-old female with sickle cell disease complicated by sickle hepatopathy and cirrhosis, was admitted to the ICU for decompensated cirrhosis, obtundation, and acute renal failure. Patient was deemed an unsuitable candidate for hemodialysis or liver transplantation. In both cases, after multi-disciplinary discussion with all sub-specialties, no further reversible treatments were available and CPR was deemed non-beneficial. Informed assent and non-dissent decision-making models were utilized, however, the patients’ families were unable to reach a consensus. UDNR policy was discussed with families which they accepted thereafter. The SDM for Case 2 ultimately pursued comfort measures. Both patients died in our ICU. The harm caused by CPR where further resuscitation is non-beneficial must be balanced with the principle of non-maleficence, as proceeding with this intervention can cause moral distress. End-of-life decision-making can also cause significant distress to family members with long-lasting negative consequences. Informed assent or non-dissent are clinician-directed discussions in which the clinician provides a clear recommendation against CPR, giving surrogates the opportunity to agree or disagree, respectively. In both cases, despite utilizing this model, the families were unable to reach a consensus. Given the impasse, our UDNR policy was discussed to which the families expressed understanding and acceptance, shifting the burden of decision-making away from the family. In these instances, the institution of UDNR while still attempting informed assent or non-dissent provided clarity in clinical prognosis and medical futility of certain interventions while still respecting family involvement and minimizing emotional guilt within decision-making. In both cases, multi-disciplinary discussion between sub-specialties agreed that CPR would be non-beneficial, highlighting the importance of multi-disciplinary concurrence with involvement of ethics committees when appropriate. UDNR orders can prove to be a valuable tool in upholding non-maleficence while alleviating family distress, and warrant further investigation. This abstract is funded by: None