Unilateral DNAR Should Be Used Sparingly in Pediatric Care

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A unilateral DNAR should be limited in pediatric care, reserved for cases in which there is abuse or financial incentive to prolong the suffering of the child.
A unilateral DNAR should be limited in pediatric care, reserved for cases in which there is abuse or financial incentive to prolong the suffering of the child.

A unilateral do not attempt resuscitation (DNAR) order should only be reserved for limited cases in pediatric care, according to a recent article published in the Journal of Pain and Symptom Management.

End-of-life care in the pediatric setting is complex and emotionally charged for patients, parents, and the healthcare team. Disagreements between parents and healthcare providers about appropriate interventions and what constitutes beneficial care can cloud the issue and interfere with the delivery of good care to the patient.

This is particularly true in the case of a DNAR, in which parents may not be ready to accept the futility of further care of their child. In rare cases, the healthcare team can be moved to enact such an order against the wishes of the patient's parents.

However, Jonathan M. Marron, MD, MPH, of the department of medicine at Boston Children's Hospital in Massachusetts, and colleagues argue that the role for a unilateral DNAR should be limited in pediatric care, reserved for cases in which there is abuse or financial incentive to prolong the suffering of the child. Instead, they suggest that the focus should be on conducting an open discussion between the parents and the healthcare team, engaging in shared decision making, and maintaining a strong clinician-parent relationship.

Given the diverse nature of our population, sociocultural differences must be respected and consideration given to individuals who do not have the means or wherewithal to object to a DNAR order. At the same time, members of the medical team who are uncomfortable with parental decisions should be supported. All parties should be encouraged to voice their perspectives in a respectful and cooperative manner.

By actively soliciting parental input, the healthcare team can diffuse potentially charged and distressing situations before they develop and provide both patient and parents with the best possible care.

Reference

Marron JM, Jones E, Wolfe J. Is there ever a role for the unilateral do not attempt resuscitation order in pediatric care? [published online September 12, 2017] J Pain Symp Manag. doi:10.1016/j.jpainsymman.2017.09.006

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