Again..Problems with the Comfort measures Only Orders

[burger914]

:angryfire

I am working in a pretty nice little facilty, where I have always felt that the DON and I were on the same page. Well, we have a new director now and the first day I worked with her was Monday. She is a straight-forward, nurse who seemed to know long term care well. We got along fine most of the day. That all changed when one of our residents went bad. (Difficulty breathing, low pulse, low pulse off, low BP.) The patient is CMO. My director said she did not like CMO orders and wanted to send her out. I have always believed in CMO, and get upset when people get sent out to die in the hospital instead of their "homes."

I said "she is CMO. her family does not want her sent out." She replied, "That is not what CMO is referring too..it refers to a long term illness not a sudden change in condition" WHATTTTTT????? Please, am I losing the few marbles that I have left???? Am I supposed to send out every CMO in Resp. Distress? Where will it end?? Sorry so long

[leslie :-D]

Pt needs a DNR/DNI/DNH order

Sorry; I'm an American, but I don't KNOW about the DNH...WHAT is a DNH,please? Do Not Help? Do Not Hassle? Do Not Harangue?

Do Not Hope?

Confuddled, Spiritus:imbar

:chuckle .....do not hospitalize. in other words, you would treat the patient at the facility where they reside.

leslie

[mandykal, ADN, RN]

Comfort measures means keep the pt comfortable only. Pt needs a DNR/DNI/DNH order specifically documented so the pt is not sent to the ER, not intubated, and NOT resusitated if found expired and advance directives by the pt or POA need to be specified, documented and followed. By comfort measures they specifically mean yada, yada, yada.

_________________

Okay, I now know what's "DNH." Now what is "DNI?" is it "Do Not Intubate?"

Thanks, student

[Kaylesh]

_________________

Okay, I now know what's "DNH." Now what is "DNI?" is it "Do Not Intubate?"

Thanks, student

Yep DNI is Do Not Intubate.. amazing sometimes how we can be confused by the same language eh? ..

Kaylesh

:)

[slinkeecat]

I had a terrible night.... I went to work and have been doing this part time job at a nursing home so I can finish my BSN. ANYWAY... I am a psych nurse and I thought this nursing home would be a cake job as I am okay with the process of death and dying... I had developed a deep attachement or fondness of this 92 yo lady who had colon cancer that was so advanced they did a colostomy and could not remove the cancer... huge mass of cancer in rectum/ colon. She said she wanted to be a DNR years ago...ANYWAY... her family at the time, about 3 months ago, made her a "CMO-Do not transport" she had been getting along fine for those three months until about 4 days ago she started falling at night. Mildly confused...The policy at this Nursing home is that if a resident does not want their room assignment changed then it will not happen.... I finally was able to convince her that being closer to the nursing station would be best and she agreed.... for 3 days and nights everything was good. Well, last night, I went in her room and talked to her and brought her some coca cola and brought her a new purple nightgown that my daughters had picked for her... she was delighted...but it was a little too long and I told her I would hem it as soon as I got back with this little sewing machine, it would take me about 5 minutes. Well, I had no more than left the room and one of my cna's screamed for me.....I went back and apparently, she was excited about the gown and put it on and when she took a step, she caught her foot in the hem and she fell. That's what she told me in tears... well, she had major injuries... a compound fracture to her hand, external rotation to her left hip with about 5 inches in length loss compared to her right hip, and severe back pain.... I called her family... a niece that does not seem to give a damn about her and never visits and she said ... I don't want her sent out, just let her die, she is a DNR and CMO.....I told her that Acute fractures are not "COMFORTABLE" and I was obligated to call her attending and send her for eval at the ER....I was polite and matter of fact... I called her MD and he told me to send her immediately.... I did and the EMS crew came and they have know her for years and were very careful and loving in the way they took painstakingly good care of her in stabilizing her fractures before transport...I called the ER to give report on her transfer and the ER doc took my report and I gave him my assessment of her injuries...multiple fx's to Left hand left hip and I could feel and see gross deformity of her sacral-lumbar region. He called me an hour later and told me that my assessment was right on and that he was going to admit her against the family's wishes... for pain management and consult, but he did not think surgical repair would be an option, we both believe that she has bone mets..and that this a very bad thing, he told me that he fell in love with her because, she told him, thru her pain to call me and tell me that she would be okay... she did not want me to worry my pretty little head. Is that not the sweetest thing???? I am just devastated.... I know that this is long, but this lady is just so, well, exceptional and she is like the grandmother I never had and she is an adopted grandmother to my two little girls... I thought I could would never become emotionally attached to a patient, and damn it I am so upset that I have crossed this boundary....What a bad night....My entire staff is very upset and just as devastated... Just thought I would write down my thoughts, sorry to have gone on and on.... I gotta cry like a big baby now...... sorry.......

[burger914]

That is my big problem. DNR is one thing,I can totally go along with that. I can send someone out to the hospital for treatment without feeling I am going against any wishes. But, when I see CMO, Do not hospitalize, No IV, No tubefeed and my DON wants to send her out, I get upset. I should have been my more specific in my original post. The patient had a signifigant cardiac history, but it was a pretty acute change from the previous day. But to me if someone has all the above checked off how can you send them out and not feel you are going against their wishes??

[spiritus]

To Slinkeecat;

Ah, darlin', I KNOW how badly one feels when things like this happen,

and for all of the clinical prim and proper advice you get on handling your grief.

or your anger, all I can say is, Thank GOD there are people out there like you!

IF you ever want to come to England to work with me, when I qualify, you

will be welcome with open arms!! There are TOO many nurses who forget that

we HEAL, we do not CURE. What you did, for that lady, was what we are all trained to do, to do as if that very being in the bed is OUR RELATIVE, not just

some stranger.

What REALLY, REALLY matters RIGHT now, is to learn, and process, whatever lessons this

episode has taught you. And to hand them down to the next generation

of nurses who want to save the world, and realise that they may only be able to save a tiny piece of it.

God bless you, Lady!! Your story had me in tears, but they were good ones.

Always, with great respect, Spiritus:saint:

PS The angels are for you, my dear. God bless your path always...

[renerian, BSN, RN]

I am with you. I have advance directive stating exactly what I want done and exactly what I don't want done.

People change their minds all the time when it comes down to not being able to breath. I do think the facility needs to orient everyone on the policy once they figure out the definition of such.

renerian