Navigating Unilateral DNAR Orders: Findings from a Decade of Ethics Consultation Cases

Unilateral Do Not Attempt Resuscitation (UDNAR) orders remain contentious in the care of seriously ill patients. While some regard UDNAR orders as reducing non-beneficial treatment, others raise concerns around patient autonomy, potential discrimination, and the risk of relational stress between healthcare teams and families. Ethics consultation services (ECS) are often engaged when these decisions are disputed, but data on their role is limited. In this study, we conducted a retrospective analysis of ethics consultations over a 10-year period at a quaternary academic hospital to identify consultations involving UDNAR orders. We identified 58 ethics consultations (55 adult and 3 pediatric) requested in the context of UDNAR orders. There were thirty-seven (63.7%) cases in which the patient and/or surrogate actively disagreed with the proposed code status change, 21 (36.2%) cases in which they assented. We explored contextual features and palliative care involvement using a qualitative conceptual content analysis. We found that Black or African American patients were disproportionately represented among cases of conflict with a proposed UDNAR status change (p = 0.0015). Palliative care was involved in most conflict cases (28, 75.6%) while less frequently in assent cases (8, 38.0%). Our study aims to inform best practices and underscore the ethical intricacies of UDNAR decisions and the need for interdisciplinary collaboration and direct engagement with patients and families.