DNR question

[getoverit]

Hey, I had a patient yesterday and wanted to share a story, then get everyone's opinion.

A 53 year old lady with a 40 pack/yr smoking history was admitted with end-stage pulm fibrosis and stage 4 lung ca. She was made a DNR. She had obviously been a beautiful woman before lung disease got her, she had very mysterious eyes and long gray hair, very sweet and kind disposition. I was her nurse for the shift before she died.

Anyway, she pulled her oxygen off before I realized what she had done. Her sats dropped into the low 40s (with an excellent pleth that correlated with her EKG) and her rhythm changed to a-fib between 170-210, BP 60/30. Her family asked if this was the end, I said yes and then her husband said "Is there anything you can do to slow her heart rate down and bring her blood pressure up?"....loaded question for sure.

I told him I'd speak to the MD, we conferred and the decision was made to give her some diltiazem, start saline @ 100cc/h and place her back on her neosynephrine gtt. I did all this and eventually she returned to her baseline, which was poor to begin with.

Her doctor came in that morning and was upset over what had happened.

My thoughts are:

1. A DNR does not translate to Do Not Treat. I wasn't resuscitating her and if she had been in EMD it would have been a different story.

2. Her HCPOA/husband clearly stated what he wanted me to do.

3. I spoke with the on-call physician and reached the decision that we acted upon.

When my shift was over, I told her that I'd be thinking about her while I drove home....she reached out, grabbed my hand and said "I'll be thinking about you too, honey". It really moved me, I told her not to bother thinking about me and to focus on herself and her family. She smiled and that's the last I saw of her.

I'm not in trouble, her doctor isn't angry at me and I'm definitely not looking for anything resembling legal advice about DNRs. What I want to know is: do you think I did the right thing? why or why not?

I've been thinking about it almost constantly.

[nessa_5555]

I live in a small town 45 minutes east of Toronto Ontario Canada. The facilities (Retirement homes, Nursing Homes, Hospitals, Home) the DNR forms that are filled out by the patient or SDM (Substitue Decision Maker) clearly state what kind of DNR they would like. Either it be Comfort Measures Only, No Intubation, No CPR etc. This is a legal document. It clearly states what the patient wants done when death is certain. I do agree with what you did though. I would have done the same thing. Not only did you assess the situation correctly, you consulted with the on-call Physician. There should be no question in your mind about what you did. You showed compassion for the family, for the client. Bravo to you

[Ruby Vee, BSN]

i think what happened here is that the family did not have a clear plan in place with the doctor when she was made a dnr. this is the time when a doctor should talk about what the family's/pt's wishes are. what can they expect during her last days/weeks? what do they want done? he also needs to discuss hospice and what comfort measures would entail.

i am sorry you were put in the situation you were in. i understand when a pt is monitored and has vitals signs like you stated you were obligated to call the doctor. my question is why was this terminally ill pt with a dnr on a monitor? i think a quiet hospice room would have been more appropriate.

my hospital has a renowned hospice unit -- so i'm told. the difficulty is, that even when we make a patient a dnr, we keep them in our icu. with monitors. many places don't have policies that allow for a nice, quiet, appropriate hospice room.

[WalkieTalkie, RN]

I agree with the OP's actions. At my hospital a DNR is simply a DNR. If a patient/family doesn't want pressors, intubation, shocks, etc, there is a difference. We use a DNAR form that has check boxes for every kind of intervention. There are some patients who want no shocks but cardiac meds, no intubation, but want to be cardioverted, etc.

I really like using this form because it clears up a lot of confusion.