A 78-year-old male client with end-stage pancreatic cancer is enrolled in inpatient hospice care. The advance directive and the chart clearly document a Do-Not-Resuscitate (DNR) order. The client becomes apneic and pulseless. Two adult children at the bedside become distressed and demand that CPR be started immediately. Which is the priority nursing action?

A documented DNR order is a binding clinical directive that overrides family requests for resuscitation. The legal and ethical standard is to honor the written wishes of the patient. The priority is to (a) withhold CPR, (b) provide compassionate communication and presence, (c) summon the hospice/palliative care team, and (d) support the family with bereavement resources. Option 1 violates the directive and the autonomy of the patient. Option 2 dismisses the family and compounds acute grief. Option 4 partial resuscitation is not a recognized compromise; any active resuscitative intervention contradicts the directive and is ethically inconsistent.

In-depth explanation

<span class="merci-scenario-label">Clinical Judgment</span><br>Apply NCJMM: Recognize cues (<span class="merci-kw">documented DNR + apneic and pulseless + family demanding CPR + acute grief</span>) → Analyze cues (advance directive is binding; family request cannot override) → Generate solutions (withhold CPR + compassionate communication + hospice team + bereavement support) → Take action (no CPR, presence, summon the team, support the family) → Evaluate outcomes (autonomy honored, family supported, bereavement initiated).<br><br><span class="merci-scenario-label">Memory Tip</span><br><span class="merci-kw-mark">Patient autonomy > family wishes.</span> A documented DNR is binding even when family demands CPR in the moment. <span class="merci-kw">Nurse role = honor the directive + emotional presence + summon the palliative team.</span><br><br><span class="merci-scenario-label">KR vs US</span><br>In Korean practice, CPR is often performed at end of life because the family demands it. In the US, advance directives and DNR orders are legally binding. NCLEX always treats <span class="merci-kw">written patient wishes as the priority</span>, and <span class="merci-kw">partial resuscitation as a compromise</span> is also wrong.

Clinical scenario

<span class="merci-scenario-label">Clinical Practice Guide</span><br><span class="merci-kw">AHA & ANA position statements + state DNR statutes</span>: a properly executed advance directive (POLST/MOLST in many states) is legally binding. Healthcare staff must honor the directive even when family requests differ. After expected death, post-mortem care, family bereavement support, and hospice/palliative team follow-up are standard.<br><br><span class="merci-scenario-label">Caution</span><br>NCLEX traps: (1) <span class="merci-kw">"family insists, so do CPR"</span> (autonomy violation), (2) <span class="merci-kw">"explain DNR rules and dismiss family"</span> (lack of compassion), (3) <span class="merci-kw">"partial CPR as a compromise"</span> (ethically inconsistent). The fix is always to honor the directive plus active emotional support.

Key concepts

• Do-Not-Resuscitate (DNR) order — A medical order, derived from the advance directive of the patient or a surrogate decision in the absence of capacity, that instructs healthcare staff not to perform CPR in the event of cardiac or respiratory arrest. May appear on a POLST/MOLST form depending on state law. Other end-of-life interventions (oxygen, comfort medications) continue per the care plan.
• Advance directive — A written legal document in which a competent adult specifies preferences for future medical care if capacity is lost. Includes a living will (treatment preferences) and a healthcare proxy / durable power of attorney for healthcare (designated decision-maker). Honored by healthcare staff and binding under state law.
• Bereavement support — A coordinated set of services for family and friends after a death, including initial presence, follow-up calls, written materials, referrals to grief counseling, support groups, and chaplaincy. A standard component of hospice and palliative care; often continues for 12-13 months post-death.