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DNE: Do Not Escalate. An Underutilized Directive

Many people are familiar with the medical orders DNR (Do Not Resuscitate) and DNI (Do Not Intubate) which communicate a patient’s desire not to receive CPR or be placed on a breathing machine (ventilator). These decisions are usually made at the extremes of age or illness, when it is acknowledged that doing either of those things (ie doing CPR and/or delivering artificial ventilation) would not achieve a good result. Implementing DNR and or DNI is a communication about a desire NOT to receive aggressive care.

But what about when someone is already receiving a lot of care to sustain life, and that life becomes undesirable? That’s when DNE, or Do Not Escalate, comes into play. Sometimes the decisions to provide care that prolongs life are made in necessary haste, but the consequences are not welcome. Such is the case for many patients and families living in Skilled Nursing Facilities (SNFs) or Long Term Acute Care facilities (LTACs). Withdrawing any treatments can feel too severe, but many people request that nothing further be done to prolong their lives, in other words, they opt to “let nature take its course” if any further insults or degradations to their condition occur (such as a new infection or organ failure).

At that point, instead of withdrawing any measures already in place, a decision is made to focus any further efforts on the comfort of the patient and not on “fixing” new problems.

To be sure, this can be a tricky and somewhat illogical course of action on the face of things, but it allows patients and their loved ones a way to let someone go in spite of previous efforts to keep them alive at any cost. This article by Dr. Jessica Nutik Zitter beautifully illustrates the use of the Do Not Escalate medical order to deliver the most humane and ethical care possible for a dying patient.

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