DNR- Do Not Treat? - Page 3

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  1. Jun 18, '12 by
    This is the kind of thing I see with fair regularity in our ICU. You did the right thing. DNR does not mean "Do not treat" regardless of the hard time people were giving you; I don't really understand why people have a hard time of grasping this (not you, but the people that were giving you a hard time; it's pretty cut and dry). It means do not resuscitate, so you do everything for the patient you would normally do, except CPR, ACLS drugs, and intubation (or whatever your hospital policy dictates). They were giving you a hard time because they believed the patient should die, but their beliefs don't matter. DNR means DNR, and it's the next of kin's decision, even if they make what you believe to be the wrong choice.

    So, fluid boluses are appropriate even though you know this poor person is terminal and ready to die.

    What you could have done if you didn't do it: you advocate for your patient, and tell the doc the first time over the phone that this patient is a DNR, and terminal. You need to come speak with the family regarding prognosis and making this patient comfort care only. So, he/she facilitates that discussion with the family (since it is beyond our scope to initiate that discussion even if it is obvious what the prognosis is), and the next of kin makes the decision on how they want to proceed, continue with treatment or make the patient comfort care.
    DeLanaHarvickWannabe and jadelpn like this.
  2. Jun 18, '12 by
    I understand your desire to keep the patient alive until family arrived. I can see your dilema but, there does come a time when treating a rapidly declining DNR is like beating a dead horse, no offense or pun intended. A patient that sick requiring drips and bolus' should probaby have been in an ICU or CVICU to begin with regardless of code status. If that had been me I would have sought a Withdrawl of Care from the family. Assuming the family agreed, I would have then called the MD and notified him of the families decison to withdraw care and asked him to make the patient Comfort Measures only which in most case means death is immanent. Generous amounts (hopefully) of morphine would have been prescribed and the pt would have been allowed to pass in his/her own time comfortably. if the family did not agree to withdraw care despite having explained the pts situation and the fact that death was not a matter of if but when, then I would have called the MD and asked for a set of standing orders related to blood pressure maintenance and pain control. I don't know that this answers your question entirely but hopefully it helps.
  3. Jun 18, '12 by
    I am sorry you did not get the support you needed.

    From administration.. to the doctors.. to the rapid response team. In my facility. I would expect the RRT to assist me..as this was not a code. Look at their job description .. that will tell you what you need to know about THAT issue.

    The treatment of a DNR designated patient has been an ongoing issue in my 30 years of nursing.
    We would think (and hope) that , this extremely important issue would have been clarified by now!

    Legally, you needed to treat the low blood pressure and the patients decline . Morally? who knows.. ethically? who knows?

    Consider taking this to your hospitals ethics committee. Your management is wishy-washy at best.

    You did the best you could.. given the mess you were handled.
  4. Guide
    Jun 18, '12 by
    Quote from MN-Nurse
    That being said, if you are going to call rapids for people with a DNR order, you better be real clear on what you want them to do for you.
    This.
  5. Jun 20, '12 by
    do not resuscitate means just what it says...it doesn't mean do not treat. in cases of terminal illness many physicians will order comfort measures only in addition to the dnr (after discussing this with the family of course). since this isn't mentioned i assume this wasn't the case and i would have done as you did and continued to get orders and treat symptoms as they arose. you did nothing wrong given the orders and situation you describe. we in the health care field must advocate for our patient's and their families. the fact that you put the needs of the patient and family first, regardless of how co-workers treated you, tells me you are the nurse i would want caring for my loved one when the time comes. kudos to you...and i would have to question if some of the health care workers you encountered are in the correct job or maybe should be considering retirement.
  6. Jun 21, '12 by
    I was in a similar situation. The patient had a No Code order, but was clearly septic (tachy, hypotensive, diaphoretic, source of infection, lactic and white count through the roof, etc). She was declining steadily on my shift, and I was torn. Do I call the doctor and initiate severe sepsis protocol (which would likely end with her intubated), or do I allow her to continue declining? I went with my gut, called the doctor, got some orders that would stave off some of the worse symptoms without doing SSP, and as I hung up with the doctor she died. I was glad I at least called and got orders, even though in the end it was futile. That was an awkward call to the doc 10 minutes later, though.
  7. Jun 21, '12 by
    I think you did the right thing. After all , you called a rapid response team not a code team. You may get some of the same people for both but the functions of each are different. Sometime a rapid response evolves into a code. Many times they do not. The way I see it is you got to a point in this patients care where you needed to see if there was some other option and you tried to get opinions from more highly skilled people. Unfortunately, they failed you. Sounds like they may need some more education.

    It might be well to address their responses with your nurse manager. Those kinds of responses can keep nurses from calling rapid response teams which, in the end, is a bad thing.