DNR and pacing.

classicdame, MSN, EdD · May 7, 2012

we would not pace a DNR. What are you going to do if you get a fatal rhythm? Could get sued by family if the patient has signed a DNR order

BacktoBasics · May 7, 2012

I would pace a DNR. It doesn't mean you don't treat. If a patient develops 3rd degree heart block, you pace them. It doesn't matter if they go into a deadly rhythm or not because you don't pace deadly rhythms, you shock them.

ClearBlueOctoberSky · May 8, 2012

In the State of Colorado, when a patient is a DNR, that includes NO external or internal pacing, NO cardiac medications, NO intubations, NO rescue or "helping" them to breathe. In other words, no cardiac heroic measures unless the patient requests it. As a Paramedic, I learned the hard way, as this wasn't included into the education on DNR's.

netglow, ASN, RN · May 8, 2012

That is an interesting question. If this is new onset cardiac, then it needs to be discussed with the patient. Sometimes when someone for instance has terminal cancer, they know they planned for that - thus the DNR. They might have been given a time line and what to expect. Something new might pop up on the scene unexpected. Plenty of times the patient may want it treated if it is not complex, and can be treated easily if not part of the terminal dx so that they can live a bit longer... sometimes they welcome the other thing and hope it kills them first, you know? Thing is, you always got to go over it with the patient and see what they want to do.

Pacing in itself is not resus - and I would not want to worry about falling down stairs and cracking my head open at any random time if that was not my terminal dx.

squatmunkie_RN · May 8, 2012

Why would you pace someone who's DNR? They are dying without machines to sustain them...which is what they and the family wanted. We don't do that on my tele floor. We let them die naturally.

Jenni811, RN · May 10, 2012

hmmm...on this site we are about 50/50 too? Seems to be the census with the nurses and doctors i've asked as well. I always thought PACING a DNR patient would be ok. Obviously i wouldn't shock a patient if he went into a fatal rythm. Because by just pacing we aren't resucitating.

Maybe i should bring it up to the nurse educators. But i like the answer that this needs to be discussed with the patient when they are deciding DNR status.

Do Dr's discuss pacing with patients when talking about code status? I've never heard a doctor even bring up pacing but they talk about shocking, CPR, intubation etc.

OnlybyHisgraceRN, ASN, RN · May 10, 2012

Interesting question. I'm 50/50 too.

psu_213, BSN, RN · May 10, 2012

Most of the DNR statements that I have spell out what is to be done. For example, yes/no on intubation, CPR, cardiac drugs, defibrillation, pacing, etc. Considering the potential discomfort to the pt with pacing, I would say that a true "DNR" should not be paced.

nurseprnRN, BSN, RN · May 10, 2012

if the slow decline from sustainable rhythm to brady to pauses to longer pauses to death is expected (or at least not unwelcome, all things considered) as part of an expected decline, i would never interrupt it by pacing, any more than i would by shooting in chemical resuscitation, cardioverting/defibrillating, or laying on of hands in cpr. death, sometimes, is a good idea, and people are not always afraid of it.

i think when people think they (or a loved one) is dnr, that means, "leave them alone if they try to die." the average person has no idea that pacing is part of the toolkit, so it woud not be fair to ask what they think of it without a full discussion...and this is not the time for that. let him go, since it seems to be everyone's wish except the on-call doc who doesn't want to take the time to get to know all the issues for this particular patient/family and doesn't want to make out the paperwork if he dies.

Jenni811, RN · May 14, 2012

Eeeeek. I brought it up to my manager in fear an issue like this may come up again. And we all had different opinions.

I myself, would pace because the definition of DNR status is you CAN do things to prevent cardiac arrest and pacing would fall under that category. Anyway...tats my opinion, i don't mean to leave this up for debate because i do see the other side too and this is why i asked.

So i said this issue NEEDS to be addressed because if this were to come up you got 50% of the people yelling "do it" and 50% yelling "don't do it!" patient may not be able ot make that decision, family isn't around or whatever. you never know the scenerio. She just said she would take care of this and bring it up to me but thinks that pacing needs to be discussed with patient and family. All other issues besides cpr and intubation need to be discussed such as medications and pacing.

this particular patient i was talking about was in with syncope. Found to be bradycardic (low 30's and highest of 40). Also having frequent pauses that were getting longer and longer. Any normal patient, pacer patches in place were a good option.

akulahawkRN, ADN, RN, EMT-P · May 15, 2012

Typically, DNR means no chest compressions, defibrillation, no assisted ventilations, no intubation, no cardiotonic drugs, no pacing. Why? These things are geared toward resuscitation. I wouldn't pace a DNR patient, even with a demand pacer without an order (with patient consent) to modify the DNR order to allow pacing. A way to think about pacing in this situation is that it's CPR using electricity instead of your hands to keep the blood pumping through the heart. If you wouldn't do CPR, you wouldn't pace.

The patient in question? I wouldn't pace. It might be prudent to discuss the issue with family and/or the patient though.

That's my $0.02 on that.