I work out west so I don't know how you want to categorize me but:
I was wondering what experiences people have had with DNR, DNI, and comfort measures in the ICU setting. What type of communication do your doctors have with patients and their families about end of life issues?
We use a LOT of family conferences. We, the primary nurses of a patient, are also pretty aggressive with our discussions about DNR/switching to DNR with family. We have had, fortunately, great social workers and a palliative team that has taught us well how to express quality of life, prognosis, and the pt's wishes to patient's families. You'd think the pt's wishes would direct their care if incapacitated and put into ICU setting but....... sadly, the family will try to override the care as I'll explain in a second.
Is it appropriate to intubate a patient that has a DNR but not a DNI? Do doctors hold up advance directives or do they push families to make more aggressive decisions? Do doctors talk about prognosis with families before starting aggressive treatments like CCVH/dialysis or HFOV? Is code status even discussed with patients/families when patients are admitted? Are pressors indicated for a DNR patient? Does your facility have a set DNR protocol or is it a big shade of gray for everyone who comes in?
1) Physicians will discuss code status and aggressive treatments when it's possible first. Sometimes, we just get a patient found down, no prior known POA, code status, advanced directives, and at that point, we have to treat them as a full code that would want everything. If family is available, then it is discussed first. Unless, again, the situation is absolutely dire, family is unreachable, then the physician will begin what's necessary if care has not yet been well delineated.
2) DNR does not necessarily mean DNI. We have DNR's that say chemical code only, DNI, can intubate, etc. Some are as educated as to say do not give pressors. If the patient just has DNR, intubation can be considered a possibility if they go into respiratory distress. Technically, that is not resuscitating at that point. This is why we have DNI status patients. This is the same for pressors. Sometimes, we also do this (provided the pt has not said "DNI") to keep the pt alive for family to come in. Usually this is a conversation about how their family members wishes are DNR etc., they are doing poorly, and they are on life support. Family will ask to keep them alive just until they can all come in and say good bye, and then we switch to comfort care. UNFORTUNATELY, if a patient loses the ability to direct his care, and even if he is documented DNI, in our state, the POA automatically goes to the closest, eldest living relative. And we have had many cases where they direct us to go against their family member's wishes. It's a crappy situation all around when that happens.
If and when comfort measures are implemented what types of things do you stop or continue to do? Do you still take vital signs or draw labs? Are these patients sent to the floor or are they left in the ICU for continuity of care?
We don't draw blood anymore, but we do take vitals. Vitals is very helpful for us to direct if they need more medication to keep them comfortable.. e.g. if they're starting to desat slowly, you don't want them to be showing signs of air hunger while family is in watching them pass. Our number 1 goal is to give the family and pt as much uninterrupted time as possible, only interrupting to specifically intervene to keep their loved one comfortable (medications, maybe suction the mouth so they don't aspirate secretions, etc). Now mind you on ICU most of our patients don't take more than a few hours to pass on when they are turned to comfort care because it's usually withdrawing life support. I know outside of the ICU comfort care patients have held on for days
and then they may go in and turn the pt, something we don't do. Very rarely do we have a comfort care patient that was not a withdrawal of life support patient as well.