No rapid response for a DNR?

[AlphaPig]

This wasn't my patient, but last week on my med/surg floor a LOL who happened to be a DNR suddenly developed an irregular very fast heartrate and became less responsive. It was early in the shift, and because the patient's heart rate went from a baseline SR in the 70's to irregular in the 140's/150's, the nurse called a rapid response on the patient so an ICU nurse came over and evaluated, a stat 12 lead EKG was ordered,etc. Just standard. I was half paying attention to this while assessing my own patients just to see if the nurse needed any help with the rest of her assignment.

Anyway, when the attending physician arrived to do his rounds, he was *#$$&%. Stood at the nurse's station loudly complaining "Why was a RR called? She's a DNR!!" and was curt to the nurse and yelled to "just consult hospice" and "don't do anything" and told the ICU nurse to leave.

Now, to me, a DNR order is not akin to a "comfort measures only" order. I mean, if the lady coded we would not have tried to resuscitate, but she wasn't coding, only showing new cardiac symptoms.

The nurse was upset and thinking she did something wrong. I told her that she did the right thing for the patient.

What is your opinions? I know that there are a lot of details missing here, but just the general question of do you call a RR on a DNR patient?

[Penelope_Pitstop, BSN, RN]

I don't why a DNR was on telemetry in the first place. Putting a DNR on titrated drips is resuscitation.

DNR means that in the event of cardiac or respiratory arrest, no attempts will be made to resuscitate. That also means we are going to do everything in our power to prevent that cardiac or respiratory arrest.

Titrated drips are not CPR. DNR means no CPR.

[SoldierNurse22, BSN, RN]

If a pt is in the hospital with a telemetry box on, no pt is going to die peacefully in their sleep. And no know dies instantly. So, that means there is going to be an intervention at the first sign of end of life.

Not sure where you heard this. I've seen many a patient just stop breathing, go completely pulseless and just drop off. And yes, with proper medication for pain and attention to comfort, many patients DO die comfortably in their sleep.

[SwansonRN]

Never be afraid to call a rapid response. The worse that can happen is some jerky doctor chews you out (even though in this case he's wrong!) Absolutely do everything you can for a DNR that the patient/family is okay with. It only means do not resuscitate. Don't add more to the story than that unless there are specific circumstances in that particular case.

[uRNmyway, ASN, RN]

Not sure where you heard this. I've seen many a patient just stop breathing, go completely pulseless and just drop off. And yes, with proper medication for pain and attention to comfort, many patients DO die comfortably in their sleep.

Um, yes, what SoldierNurse22 said. First, telemetry box or no, a patient who is going to die in their sleep is going to do so whether a machine is beeping in their ear or not. I mean, really, if the way to hold off death is a telemetry machine being hooked to you, why isn't it being marketed as such?!

And seriously, with two close family members who went very quickly (one was getting ready for visitors, primping, and just dropped to the floor, gone instantly. The other had just been set up in his chair for dinner, nurse turned to get his tray, back to him, gone.), all I can do is shake my head.

Here is a bit of info for ya, basic definitions.

DNR-In medicine, a "do not resuscitate" or "DNR", sometimes called a "No Code", is a legal order written either in the hospital or on a legal form to respect the wishes of a patient not to undergo CPR or advanced cardiac life support (ACLS) if their heart were to stop or they were to stop breathing.

And RESUSCITATE-Definition of RESUSCITATEtransitive verb

: to revive from apparent death or from unconsciousness

So if the patient still has a pulse, is still breathing, heck, awake and talking? I mean, how is this going against the DNR?!!?

[hodgieRN]

And RESUSCITATE-Definition of RESUSCITATEtransitive verb

: to revive from apparent death or from unconsciousness

Right....

[hodgieRN]

and became less responsive.

I don't find my response ignorant

[Dodongo, APRN, NP]

When the family fills out a code sheet the provider should also discuss other treatment options such as intubation, blood products, pressors, Abx, etc. We have plenty of patients in the ICU who are DNR but are intubated and on pressor support. You treat a DNR up to the point their heart stops beating. The physician was wrong.

[That Guy, BSN, RN, EMT-B]

My favorite doc says a DNR means do everything to prevent them from coding. If it is what the patient wants. Then if they crump, let them go.

[PMFB-RN, RN]

The DNR doesn't affect anything until after the patient dies. It should not have any affect on treatment. If the physican wants the LOL on hospice then he needs to have a family meeting with her family and others involved in her care and see if they come to that decision. That physician is VERY VERY lucky _I_ was not the rapid response nurse who was on the sceen.

Did none of you stand up to him? Why was his inappropiate behavior tolerated? He was ******? SO WHAT!?

[suppaduppaCNA]

From the facts, I think the Nurse did the right thing. The patient sign-in for "do not RESUSCITATE me", not for "Watch me DIE" otherwise I am pretty sure that she will not be receiving care at your unit.

Now, I don't know why a doctor would react this way. He might know something that the Nurse doesn't or the Nurse missed something..Either way there is a communication problem here and that's NOT good!

[KelRN215, BSN, RN]

In the pediatric hospitals I've worked, there are different "levels" of DNR/AND and it's usually fairly well defined how aggressively we will treat. Some DNRs calling a RRT would be appropriate, others it wouldn't. Hard to say in this case with limited info.

I agree... pediatrics is a very different world though. I've seen DNR orders as specific as to include "no oxygen, no suctioning, no venipuncture, no cardiac meds" etc. The difference is that, in my experience, a child who is a DNR is probably actively dying whereas a little old lady might be otherwise healthy but just know that she does not desire CPR in the event that she happens to die unexpectedly. OP, you don't say what this lady was admitted for or what her status/baseline prior to this event was so it's hard to say. I can't think of any pediatric DNRs who I would have ever called a rapid response on, but the patients I'm talking about were usually on morphine drips with all interventions stopped and the end nearing very quickly.

[turnforthenurse, MSN, NP]

The nurse was right and the MD was just plain wrong. DNR does not mean "do not treat." If the patient arrested, that is when the DNR comes into play.