Heroic measures on a full DNR pt?

  1. I work in an ICU setting at a large teaching hospital (1000+ beds). Lately there has been this mindset among the docs regarding how far we should go when a pt with an in-hospital "do no resuscitate" order is going down the tubes.

    Our DNR form is basically divided into two sections: "full DNR" says something along the lines that "in the event of cardio/pulmonary arrest no measures should be taken, including intubation, vasoactive meds, shock, cpr, etc". Then there is "modified DNR", in which the pt/family/doctor picks out which treatments we can/cannot do. I imagine this is pretty standard, based on the several hospitals in which I've worked.

    So here is an example. Had this full DNR pt who was already intubated prior to the DNR order, whose BP was crashing. Doc wanted to start her on vasopressors. We jumped up and said no way, the pt is full DNR, all we can do is give fluid. The doc said technically since the pt hasn't "arrested" that we can do whatever.

    This did not make any sense to us, so we called our legal department in the middle of the night to get more info. Legal said that the doc is correct and that we should do whatever to save the pt's life!! Our unit manager was made aware of this too, and she said the same thing. We were totally shocked!!

    In my opinion, starting vasoactives based on this situation is unethical, and our pre-printed DNR order sheet is rather unclear. Even though the pt hasn't lost her pulse, myself and all the other nurses in my unit agree that this is a heroic measure that either the pt or the next of kin doesn't want.

    I mean how far can one take this? If there was a full DNR order on a pt who wasn't intubated already, and suddenly went into resp distress (but not apnea),... would they want us to intubate?? In the minds of these docs, she "technically" hasnt coded yet. It's crazy!!!

    If my family member was DNR, and I came in the next morning to find that they were intubated, shocked, and on drips, I'd be infuriated! I could also picture some people taking legal action as well.

    Any feedback from you guys? Anyone else have a similar issue at their hospital?
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  2. 12 Comments

  3. by   nyapa
    In our country our situation is just as dependent on the doctors opinion. However if the DNR (NFR) order is written, a doctor is not on the ward, then we nurses are expected not to resuscitate.

    I agree with you. I hate it when the allied health professionals and medical teams get proactive ie, dietitians love getting you to weigh ppl who are dying and bedbound, doctors insist on active medication etc etc, pushing of fluids, insertion of NG tubes and PEGs. Where is the dignity?
  4. by   jbp0529
    Just adding a few points to my original post. At my place it seems like the docs love to flog and push pt's to the breaking point, even when its clear to everyone that treatment is futile. I've told a few docs on the side that death is a natural thing, and that one day it will happen to all of us. The fact that pt's die doesn't mean that they as MD's have "failed", and that there should be some dignity and respect to pt's/family wishes. DNR doesn't mean "do not treat", but it also doesn't mean putting someone on Levophed up to infinity just bc there is a technical glitch in the writting on the DNR order form.
  5. by   fins
    I work in a neuro ICU, so I share your frustration with futile measures at end of life. I have someone with a GCS of 4 and a CT that's more blood than brain, but the family wants everything done because "dad was always a fighter" and sometimes I want to put my fist through a wall.

    However, there is a difference between do not resuscitate, and withdrawal of care. And if a patient hasn't coded, then the DNR isn't operative yet.

    I hate pouring time, effort and resources into hopeless cases as much as you do, but it is the family's responsibility to say stop, not the health care team's. We might try to educate the family about prognosis, pain, dying etc, but in the end it's their call.

    The alternative is already in place in other countries - doctors withdrawing care against family wishes, first because it's hopeless, then steadily as time moves on "quality of life" factors creep in. And then finally cost of care factors creep in. And I'm sorry, when I look at some of the docs at my facility, I wouldn't trust them to decide when my dog should be put down. They sure as heck better not be deciding whether my grandmother deserves a ventilator or not.

    So yeah, we need to keep trying until the family says stop. It's loathsome sometimes, but there are systems out there that are even more loathsome.

    If the family doesn't want pressors hung, they either need to make the patient comfort measures only, or else get a very specific advanced directive drawn up, because like it or not, until the patient codes, the DNR isn't operative.
    Last edit by fins on Nov 26, '07
  6. by   jbp0529
    So I dragged out my hospitals DNR form (I'm a dork, and have copies of blank forms from my hospital that I use for reference at times).

    There is a spot on the form that has "treatment limitations". Goes through a list of things like "pressors, intubation, shock, antiarrhythmics, blood products..."

    Perhaps what we should be doing on my unit is encouraging the docs to fill in that portion, as well as the other parts. That way, if the pt doesn't want vasopressors, they dont get them (if that is their wish). Even if they haven't actually lost a pulse and "coded".

    Because my initial point still remains an issue. Where does the treatment cross the line? Do we intubate on DNR pts (who havent gone apnic and coded yet), because of something like respiratory distress, for instance? If they are bradycardic (but not in asystole), do we push atropine or pace?

    We have a committee at my hospital that reviews things like this. I think it might be wise to bring some of these issues to them.

    FYI, we have a separate form for withdraw of care, which is different (different in that we use it when a pt has everything going on already, and we are pulling the plug, per-se).
    Last edit by jbp0529 on Nov 26, '07
  7. by   Lorie P.
    I can understand the frustration, our DNR orders have the following that can be checked;
    1. Limited DNR= no intubation, can do cpr :uhoh21:
    2. DNR = Care & Comfort with the following, labs, antibiotics, vasopressers, blood products, nutrition, etc, etc.
    3. DNR= Care & Comfort measures only.

    So we have a couple of docs that will check #2 and want everything done and if the pt's bp starts going down, then send them to the unit for specialty drips. Then this causes the unit to use up a bed and the units nurses get pissed and the cycle continues.

    I really wish they would come up with different forms to make it a little less confusing. Plus we get these docs that never check the form, just sign the name at the bottom where it says physicians signature. That just makes it worse, cause when I come in at 11pm and check my pt's code status, I only see the DNR form with just a name.:trout:

    So now I have to do research, inform the charge nurse, who has to let the house supervisor know and that usually means having to call the doc inthe middle of the night and listening to him rant and rave. Yet, they wonder why we nurses get sooo frustrated.

    Ok, off my soap box,!!
  8. by   Jo Dirt
    The patient is dying and the doctor want to play God by prolonging the patient's life a few days. I hope I have a doctor with more sense than that one has.
  9. by   nursejohio
    My personal fav is when a patient has very clearly and cognitively made the choice to be a full DNR. He or she understand the implications/brutality and success rate of being subjected to a code and want no part of it. Paperwork is done, docs are aware etc.

    When their time is up, the family has gathered round the bedside. Pt is comfortable, on morphine/ativan or what have you, and seemed prepared to go. The family, however, can't accept that grandma/grandpa is really actively dying and freaks out, demanding everything be done. The patients wishes are explained, family continues throwing a fit until the doc caves and codes the pt. I was reading one doc the riot act after just such an occasion and his reason for doing it? Dead people don't sue, the families can. :angryfire
  10. by   ayla2004
    I think the whole thing about the being sued by the livng colours what mediine is practiced. In the UK patients are either for resus of DNR and what is attemped is deiced by best clincal outcome. Patients need their Resus status reviewed regurlary and on every admission and is a MDT(multi disclinapry team) decison.#
    I remeber being in the room of a pt in Chornic Heart Failure whom the doctors has disussed with the familly that they weren't going for any heroi measures which means she was about to go on the ICP for the dying(comfort measures only). i had orked nights the previous weej and every night we has got a medic in due to her difficulty breathing and she had been on IV furosmide et with no reall improvement. To DNR her was right and she died within 3 days.
  11. by   rita359
    DNR is for when heartbeat and respiration stop. If the patient has not progressed to that point then you still treat. Give whatever is ordered until then. If patients and families knew we were going to pick and choose what we would give the patient if they were a DNR very few people would choose to be a DNR. They are told that DNR does not mean withdrawal of care so don't withhold care. If the public finds out we are picking and choosing what their loved one deserves we won't have any dnrs. What will care be like then?
  12. by   blueheaven
    I work in an ICU setting at a large teaching hospital (1000+ beds). Lately there has been this mindset among the docs regarding how far we should go when a pt with an in-hospital "do no resuscitate" order is going down the tubes.

    I think the first sentence of your post says it all TEACHING HOSPITAL. I know the hospital I work at is a teaching hospital and see all the same sorts of situations you have described. Some of our attendings (we hate it when they are on our rotation) just don't know when to say when. I got so pissed at the doc the other day insisted that the intern push for a trach on a man who was a quad for 35 years and his brother (primary caregiver) was wavering on making him a comfort measures only. I once respected this doc, but after hearing the conversation he had on rounds that day...:P
  13. by   lsyorke
    Having just gone through this "dance" with my father, the key is to talk to the family!! My fathers doctor was obviously NOT comfortable with end of life issues. He was ready to do a ct scan, labs on my Dad who was breathing at a rate of 50/min, bp bottomed out, multi system failure, 82 years old, bad health for years, blind and had made his wishes known to me. But this doc wanted to rule out any intestinal problems from Dad's C-diff, as if the man was a surgical candidate for anything!
    I ended up fighting with the doc and finally told him if he wasn't comfortable with comfort care, then sign off and get me a doc who was.
    Dad passed 4 hours later, without tubes, ct scans and labs....with dignity.
    If ANYONE had tried to start pressors, intubate etc... without talking to me(DNR was in place), there would have been hell to pay!!
  14. by   leslymill
    If their temp is 104 will you give a Tylenol? It is the same principle really. I don't consider the doctors order aggressive but prudent. Just my opinion if it ws my MOM so to speak.

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