DNRs and ACLS

bigmona · Jan 15, 2007

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.

babynurselsa, RN · Jan 15, 2007

No, you would require a physician order.

TazziRN, RN · Jan 15, 2007

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.

GardenDove · Jan 15, 2007

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.

GardenDove · Jan 15, 2007

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.

rita359 · Jan 15, 2007

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.

Tweety, BSN, RN · Jan 15, 2007

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. :)

GardenDove · Jan 15, 2007

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.

GardenDove · Jan 16, 2007

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.

burn out · Jan 16, 2007

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.

Bluehair · Jan 16, 2007

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.