DNRs and ACLS

  1. Can a DNR/No Code receive anything else from ACLS, other than being shocked or intubated, or does everything need to be ordered specifically by a doc?

    I was talking to my co-worker last night, I had a DNR pt go into stable V-tach last night just after shift change. While I was in the room with pt, someone called the doc and we gave IV lopressor which converted him back. Then he got 150mg of amiodorone, then an amiodorone drip.

    My coworker and I are both newer to the unit, and where she worked previously on a Tele floor, her charge nurse was the one to take over in the event of emergencies.

    So, if it had been the middle of the night and I was alone and a pt had a perfusing V-tach, could I have given 150 of Amiodorone under ACLS immediately to a DNR to convert him back?
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  2. 21 Comments

  3. by   bigmona
    where i work, we have different levels of DNR. a form needs to be completed by the doc if someone is to be DNR and there is a checklist of potential life-sustaining actions that can be taken that must be checked either "yes" or "no". antiarrhythmic drugs is one of these. some patients are DNR with comfort measures only. i don't have ACLS yet but i thought that meds would need to be ordered specifically from a doc to be given to a DNR patient.
  4. by   babynurselsa
    No, you would require a physician order.
  5. by   TazziRN
    All meds are to be ordered by the physician unless your facility has standing orders. Nurses can order meds under ACLS guidelines if the pt codes and there is no MD.
  6. by   GardenDove
    This pt wasn't coding, he was in a perfusing V-tach. So we can't do any protocols under ACLS for a no code if the pt is DNR? In this case, the pt had just arrived right before I arrived at 1900. I was told he was a DNR, but no details of the POLST. This happened immediately after report. According to the SO, the pt didn't want heros, but I believe she had full-fledged CPR in mind. But the pt did have a DNR order from the doc.

    Anyways, I was unclear on that. I think alot of pts don't really understand ACLS when they sign off on no code. This pt was in his 60s with an extensive cardiac hx and according to the old chart he had a hx of going into V-tach before when he had come into the ER with CP, A&O, but feeling crappy.
  7. by   GardenDove
    Under ACLS you don't have to wait for a full fledged code to operate under it's algorythms. That's my distinction. Say a pt is a no-code and goes into SVT or perfusing V-tach. You want to get them out of the rythm, they aren't 'coding', but they need to get out of it and ACLS covers those conditions.
  8. by   rita359
    My understanding of DNR is patient does not get chest compressions and rescue breathing if the heartrate stops and respirations stop. Abnormal rhythms that could be medically converted should be unless patient is on end of life care.
  9. by   Tweety
    Where I work, unless a code blue is called then we have to get MD orders. Obviously a Code blue wouldn't be called on your patient and ACLS meds could not be given.

    If a patient wasn't in symptomatic v-tach, and a code wasn't called we still would have to get MD orders....but I would have the code cart right outside the room.
    Last edit by Tweety on Jan 15, '07
  10. by   GardenDove
    Oh, but in our unit we have epi, atropine, and lidocaine at the bedside. If the pt has a symptomatic bradycardia, for example, we are able to give them 0.5 of atropine, then call the doc. You don't need to call the doc to treat a HR in the 30's that is causing immediate problems. You would give that right away, then call for help.
  11. by   GardenDove
    Quote from rita359
    My understanding of DNR is patient does not get chest compressions and rescue breathing if the heartrate stops and respirations stop. Abnormal rhythms that could be medically converted should be unless patient is on end of life care.

    Yes, that's what I'm wondering. I'm going to discuss this with my manager for clarification, for sure.
  12. by   burn out
    Where I work the docs day that DNR does not mean do not treat.
    We had a patient one time come in tor sades (sp) and we shocked him every 5-10 minutes for 2 days-honestly could not leave his bedside some one had to be there to shock him-finally he came out of it and was doing great no deficits. The days he was to transfer out of icu the doc said to stop the dopamine (at 3 mcg) and if stable transfer to the floor. The patient had been made a dnr after all the shocking. When I came on at 7pm his blood pressure was 40 systolic and his nurse said he was going. BY the time I got to him he barely told me good-bye and went asystole I had no time to anything..I asked the nurse why she didnt restart the dopamine and she said "Because he is a DNR" I had to call the doctor then about the pt passing and he said why did't you restart the dopamine and I said because the nurse said he was a DNR. I always call now when I see a DNR patient going..I don't want to be the making thoose too important decisions on whether or not to treat the patient.
  13. by   Bluehair
    Where I am working right now they get very specific about the patient's advance directive re: DNR status, and clarify that in the MD order at the time they are made a DNR. Example: 'Pt is to be a DNR but wants to be shocked for v-tach'. DNR/DNI means do not resusitate or intubate, but you can still get shocked or treatment for hypotension, etc. if the patient wants. Comfort measures means nadda, let 'em go and keep them comfy. We do what the OP suggested, when in doubt, call the MD for clarification. DNR does not mean do not treat. It gets too fuzzy if you don't get specific clarification. We do have frank and caring conversations with our patients/families/POA to get as much clarification as possible right at admission. One of the better things to come out of the Terry Schiavo situation is public awareness, so we incorporate that into our teaching on this topic. Example: 'This is a sensitive subject, but after all the confusion regarding what Terry Schiavo wanted for her life, we want to ask you and know what your preference is. We don't expect anything like this to happen while you are here, but in case of emergency what exactly is your preference for us to do if your heart were to stop?" Patients have all been very receptive, and the answers have surprised a few family members.
  14. by   Bethy-lynn
    Where I work, we have sort of an "all or nothing" policy when it comes to DNR (i.e. they either want to be a full code, or not, we don't do chem codes, or intubation only). In fact, according to our policy, we can't intubate someone that is a DNR. However, that doesn't mean that we couldn't use lido or amioderone on someone in stable v-tach. According to acls guidlines, these could be given per protocol without calling a physician first. I think that in this case, it could almost be thought of as a comfort measure, not necessarily heroic (cause let's face it, even stable v-tach can be a little uncomfortable). Really, what would be the difference between giving someone morphine and nitro for chest pain, which could also be life-saving, and doing this? I think that if ever in doubt, it is always safer to call the MD. Also, this should serve as a reminder to all of us to be sure to have very frank and Honest conversations with our pts and fams.

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