DNR? Why not?

  1. i've worked ltc for my entire nursing career and i love my little ole men and women literally to death! what i want to know is that when they reach this point in their lives where they need us to basically help keep them functioning for as long as possible even if that means when they are in a vegitative state, i ask you, why are most of the oldtimers not on dnr status? on our unit our maximum censes is 60. right now we have 57. the average age is 73 and more than half are not dnr. why would you not want to be dnr? and what is the point? am i the only person with these feelings? i'm not sure if i should feel guilty about thinking this way about the people i take care of day in and day out.

    we have a resident who is 79 y/o and has been there 3/4 of my nursing career in a vegatative state complete with gt, has had pneumonia god only knows how many times and in my opinion should have died along time ago. the staff have come to call him "uncle jimmy." uncle jimmy"? i asked one day to another staff nurse. and she said, "oh yes, uncle jimmy has paid for all of the neices and nephews college tuition. he is 100% service connected (veteran) and receives $1600.00 a month which his brother has control over his finances and receives his money. he has made it very clear that under no circumstances does he want his demented brother a dnr!" can you imagine keeping someone alive just for their money??? there should be a law against things like that. when it comes time for uncle jimmy to pass on, a code is supposed to be called and we are to vigorously work on him. oh dear god, let the man go.



    . that only goes to show you that people will do anything for money. how cruel is that???
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  2. 37 Comments

  3. by   Talino
    Family and friends and any next of kin who decide on the residents well-being, regardless, should be treated with respect and open mind. It may look ludicrous on our part as caregivers but for them it is an emotional consolation and for others, guilt. I tend to agree with your argument that a purposeless life should be given a chance to just fade away. But a DNR is only a form. It will not hasten a man's actual "due date" on earth.

    Uncle Jimmy? "Wow, he's a gold mine!" Immoral? Maybe. But he has never been resuscitated yet, has he? For some reason, he has been allowed to live for a purpose. If I will one day be in Uncle Jimmy's situation, I would want to be kept alive too, if living would benefit another one's life, specially that of my family's.
    Last edit by Talino on Aug 21, '01
  4. by   tinkertoys
    I, too, have had many patients who I felt should have been DNR, but were not. however, that is not our decision to make. The decision to change code status is not an easy one. It is one thing to say what others should have done. It is another when we, ourselves are faced with the same decision. We cannot see into the hearts and minds of the families of these patients. We do not know the reason these precious souls are still with us. Our job is to give those patients the best care we can, keeping them as healthy, comfortable, and secure as possible, and to support and respect those who have entrusted us with their care.
    For example, we had a patient who had multiple cardiac and respiratory problems. Before coming to us, she had been resusitated multiple times, and had been on mechanical ventilation more than once. She was a full code, at her request, and with her family's support. during the nearly 3 years she was with us, we sent her out in near-code condition 12 times, and coded her once. Each time, she recovered, and returned "home" to us. Because of the care we gave to her, she and her family were able to share 3 years she would not have had, had she been a DNR.
    We will always have patients who will break our hearts, who we will grieve over because of their suffering and lack of quality of life, as we know it. But we continue to do our best to care for them, because we are nurses. That's what we do. That's who we are.
    If you are against the use of feeding tubes, etc to prolong life, make out a living will, and let your family know how you feel. Otherwise, one day, you may be the patient with the GT and IV's, simply because of a decision your loved ones cannot bring themselves to make.
  5. by   peter73
    I agree that many times a nurse may see a full code resident who has poor quality of life or is suffering as a terrible thing. We all need to step back and remember that we, as a stranger, did not know this person in a healthy state. We have no emotional ties to them, denial of impending loss, hope that they will get better or guilt over the past. Compairing the view of the residents status or prognosis between a loved one and a nurse/doctor is compairing apples to oranges. All we can do is take the best care of the resident as we can, help the family to cope with the situation and accept that our belief are just that and can never be pressed on another.
    Also a note on living wills, families can and do override living wills. I have seen this happen a number of times. I think there is no worse feeling than reinserting a G tube into a resident (full code after having a cva, being declared unable to make decisions, and living will overridden) who has spent hours trying to pull it out, all the while your doing this, begging you to leave it out and let him die. If you decide to have a living will you have to make sure that your wishes are known by everyone, spelled out exactly and hope that they are followed.
    peter
  6. by   aimeee
    As part of my job as a Hospice Admissions Nurse I must ask patients/families if they wish to sign a DNR form. Most do quite readily. Some do not. Many people equate the DNR order with giving up. I try to present the DNR as a benefit to the patient--allowing them to exit this world in a peaceful and dignified way, hopefully with their loved ones present. Whatever their decision, I support it and respect it.

    In the extended care facility the situation is a bit different since the diagnosis are not necessarily terminal. But when I worked in LTC and had the opportunity to present the advance directives for signature I always presented the patient and family with both sides of the picture. Sometimes you can just sense that a family is hesitant to say DNR because it will feel to them that they don't care deeply about the patient. Those people need to be supported and encouraged to focus on QUALITY rather than quantity of life.

    I think movies and television often do us a great disservice by making resuscitation and life support measures look so easy and successful. Zap em with the paddles and then in the next scene they are sitting up in bed chatting with the doctor. They don't show the poor souls who are brought back merely to exist for year after year of being totally dependent on others.
  7. by   aimeee
    Our LTC facility had some booklets on hand that were really wonderful for giving to folks that were struggling with the decision process. The booklet is called Hard Choices for Loving People: CPR, Artificial Feeding, Comfort Measures Only and the Elderly Patient by Hank Dunn. Here's a website where they can be ordered:
  8. by   Jackie8087RN
    I too have seen many residents that have made me question their code status. I have to wonder how well the advanced directives are explained to families. Also, I am concerned that they are not updated as often as they should be. After a change in status or a certain amount of time goes by, they should be reviewed-updated. There must be some legalities concerning this, however, I am not familiar with them. I do know that I see some that are not updated for a long time.
  9. by   betts
    I believe that Uncle Jimmy is being kept alive for monetary reasons.
    I've been a nurse in Geriatrics/LTC for 24 years and the attending physician can and should be approached. It's called 'ETHICS'.


    DWD FORM
    Death with Dignity


    REQUEST FOR MEDICATION

    TO END MY LIFE IN A HUMANE

    AND DIGNIFIED MANNER


    I, ________________, am an adult of sound mind.

    I am suffering from _______, which my attending physician has determined is a terminal disease and which has been medically confirmed by a consulting physician.

    I have been fully informed of my diagnosis, prognosis, the nature of medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives, including comfort care, hospice care and pain control.

    I request that my attending physician prescribe medication that will end my life in a humane and dignified manner.

    INITIAL ONE:

    _____ I have informed my family of my decision and taken their opinions into consideration.

    _____ I have decided not to inform my family of my decision.

    _____ I have no family to inform of my decision.

    I understand that I have the right to rescind this request at any time.

    I understand the full import of this request and I expect to die when I take the medication to be prescribed. I further understand that although most deaths occur within three hours, my death may take longer and my physician has counseled me about this possibility.

    I make this request voluntarily and without reservation, and I accept full moral responsibility for my actions.

    Signed: ___________

    Dated: ___________

    DECLARATION OF WITNESSES


    We declare that the person signing this request:

    (a) Is personally known to us or has provided proof of identity;

    (b) Signed this request in our presence;

    (c) Appears to be of sound mind and not under duress, fraud or undue influence;

    (d) Is not a patient for whom either of us is attending physician.

    __________ Witness 1/Date

    __________ Witness 2/Date

    NOTE: One witness shall not be a relative (by blood, marriage or adoption) of the person signing this request, shall not be entitled to any portion of the person's estate upon death and shall not own, operate or be employed at a health care facility where the person is a patient or resident. If the patient is an inpatient at a health care facility, one of the witnesses shall be an individual designated by the facility.
  10. by   canoehead
    You realize that in most states the doc can be prosecuted for assisting a suicide, so this form is useless, and could be used against the doctor which I am sure would not be the patient's intention.
  11. by   soulwaters
    Originally posted by tinkertoys
    I, too, have had many patients who I felt should have been DNR, but were not. however, that is not our decision to make. The decision to change code status is not an easy one. It is one thing to say what others should have done. It is another when we, ourselves are faced with the same decision. We cannot see into the hearts and minds of the families of these patients. We do not know the reason these precious souls are still with us. Our job is to give those patients the best care we can, keeping them as healthy, comfortable, and secure as possible, and to support and respect those who have entrusted us with their care.
    For example, we had a patient who had multiple cardiac and respiratory problems. Before coming to us, she had been resusitated multiple times, and had been on mechanical ventilation more than once. She was a full code, at her request, and with her family's support. during the nearly 3 years she was with us, we sent her out in near-code condition 12 times, and coded her once. Each time, she recovered, and returned "home" to us. Because of the care we gave to her, she and her family were able to share 3 years she would not have had, had she been a DNR.
    We will always have patients who will break our hearts, who we will grieve over because of their suffering and lack of quality of life, as we know it. But we continue to do our best to care for them, because we are nurses. That's what we do. That's who we are.
    If you are against the use of feeding tubes, etc to prolong life, make out a living will, and let your family know how you feel. Otherwise, one day, you may be the patient with the GT and IV's, simply because of a decision your loved ones cannot bring themselves to make.
  12. by   soulwaters
    I have worked ltc for over 7 years. It is up to the nursing staff to educate the patients families concerning the difference between dnr/full code status so that they can make the decision. The decision is not up to us the caretakers, it is up to the families. I support whatever decision they make.
  13. by   Jackie8087RN
    Please understand me. I, too, support whatever decision a family member/poa/resident makes concerning their healthcare. Regardless of their code status. I know it would be an incredible decision to have to make. However, my concern would be that the family doesn't fully understand what they are signing. I, above all else, want the patients that I take care of to be comfortably. And if that means some medication to help them relax while they are in the dying process--then so be it. I am not looking for meds to help assist with their death, however, if you knew you were dying, and were a little anxious (who wouldn't be) wouldn't you want some Ativan or MSO4 to help you relax a little. We need to treat everyone like we would want to be treated. And we do need to respect everyone's decision's.
  14. by   night owl
    Talino,

    I respect my pt's family wishes...while I'm shaking my head, but I would never have my family member kept alive in his condition, full of bed sores, bouts of pneumonia one right after another in a vegatative state just to put my kids thru college? That isn't being kept alive for a purpose, that's being kept alive no matter what to suffer...His relatives need to be euthanized for making him suffer. I wouldn't keep my dog alive like that, I'd have the poor thing euthanized! You call that "wellbeing" for that resident? LOL...

    tinkertoys,

    My intention is not to make ANY decisions for my residents, just to take care of them the best that I know how. The Doctor is the one who "steers" the family members in the right direction. I know first hand it is not an easy decision to make b/c I had to make that decision for my brother in '96. He had an aneurysim (cerebral). And I chose to pull the plug the prognosis was very poor, cerebral blood flow was zero. He was only 49 years young. My living will was made out along time ago and my family knows exactly how I feel about being kept alive on all that mess. That's not living, it is merely existing. If I can't enjoy life and have to have someone feed me, someone to make me have a bowl movement, someone to wash me up after the BM and I can't scratch an itch anywhere, what's the point??? I just want to know what these people are thinking when they want their loved one kept alive??? Are they feeling guilty for some reason, money is surely another reason, What are they thinking??? Let them go...

    peter73,

    I hope my family doesn't try to override my living will...I better go see my attorney tomorrow and tell him to insert a clause..."Under no circumstances will my family try to override the decisions that I have made in this living will"...Thanks for the tip Pete!

    aimeee,

    If the families truely loved this person, they would make them a DNR and not let h/h suffer! just my 2 cents

    Jackie8087RN,

    In our facility, the only time the DNR is brought up to the families again, is when the resident is near death. The Doc will call the family and explain the status change and the family usually will agree to it at that time.

    betts,

    The resident is Not of sound mind, he HAS NO MIND, he is alzheimer's...He is not on my unit, therefore I won't get involved. Assisted suicide is a whole different ball game and I won't go there...

    soulwaters,

    I, too support families with their decision making, but like I said...while shaking my head. I therefore take care of the resident the best that I possibly can.

    Jackie8087RN,

    Alittle medication for relaxation is a good thing when you know you're in the dying process. I know that I would want it.

    Thank you for the responses everyone, but keep them coming if you like...

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DNR? Why not?