Procedures on DNR/DNI patients

[hell000nurse]

hey all!

im currently preparing for my CRNA interview, and received a few questions from the school that i can use to prepare. wanted to get everyones take on this one:

"You have a patient in your ICU who on his living will requested to be a DNR DNI. His family has consented, however, for him to undergo an emergency exploratory lap. How do you feel about this decision?"

.....ready, go!

[nurselizk]

I believe they want to know what YOU think about the situation.

[hell000nurse]

I believe they want to know what YOU think about the situation.

yes, thank you, im aware of this. what does that have to do with starting up what i think would be a good conversation and would add to the forum?

[XB9S, BSN, MSN, EdD, RN, APN]

Hi there, lets try to keep this friendly please.

I guess the types of things that I would be thinking about would be even though they are DNR/DNI that does not mean not for treatment and the specifics of the rationale for surgery, is it paliative measures. For maybe someone who is has bowel obstruction it could alleviate pain and other symptoms , so may be of some benefit.

I would want to know if the pateint was intubated, and if not could the discussion not take place with that patient, as to what their wishes were at this time.

Another consideration would be if the family had been fully informed of the implications of proceeding with the surgery and the contents of the advanced directive, what discussion had taken place and was the consent truly informed consent.

Just a few thoughts

[suzanne4, RN]

Living will actually does not come into place until the person can no longer make decisions for themselves. It is not in place if not wrriten by a physican with this admission to your facility.

Treatment does not stop even for a patient in the ICU with DNR/DNI orders. Until they choose or their family chooses not to continue on with care, then it is done.

DNR orders are usually cancelled when the patient goes to the OR and then are rewritten again when they come out unless they specifically state or the family states that they are not to have CPR if their heart stops in the OR, which we do see every once in awhile.

Unless the patient is in a terminal condition with no chances of survival, there is no reason that I can see with not performing the surgery to begin with. Unless the patient has stated that they do not want anything done to them including any type of surgery.

[RNFELICITY]

I think my biggest problem in this area is that I have had many many patients who vocalize certain wishes and as soona s they become unconscious or seriously ill, there is some family member who sees them once a year that comes in and changes things and makes decisions that the patient has verbalized that they never ever wanted.

personally, I think there is a special place in hell for people like that.

[TX_ICU_RN]

I have only been in the ICU for a month and I am already frustrated by this issue on multiple fronts. In regards to the original post, I think the choice should be based on the condition of the patient. If the patient is alert and oriented, then they should make the choice. If the surgery is palliative...then we should do it. If the surgery is going to create potential complications and simply prolong the inevitable AND make the patient suffer...then it should not be done.

[RN1980]

this is what i've learned and seen in the various units that i've worked in during my short career as a icu nurse. the doc is most likely going to do what ever causes the lesser of strain and tension for the family and the doc. i've rarely seen a surgon turn down a case even on a dnr unless the pt is so devasted that it would be totally impracticle to do so. but there is the old saying "dnr does'nt mean do not treat".

[Endorn2012]

This is always a difficult situation that we encounter very frequently in my ICU. I think the most important thing to remember is that DNR/DNI does not mean do not treat. It sound like in that situation the patient is incapacitated and cannot make the decision. Will the surgery prolong the inevitable because of a terminal conditon. Did the family ever discuss with the patient the "what if" situations and what he/she wanted? Is it a palliative procedure? these are all questions that need to be addressed. If the patient had verbalized to staff that he did not want any measures taken and now the family has done the opposite is the staff willing to document their conversations with this person to support going against the family wishes? then there enters the ethical team. It is such a fine line and usually if it's a younger person versus the typical 80/90 years old patient people tend feel better about not tightly adhereing to a living will. besides living wills are really very basic and the important component, which often does not happen, is that the proxy has had discussions of the what if situations with the patient.

[hell000nurse]

I think my biggest problem in this area is that I have had many many patients who vocalize certain wishes and as soona s they become unconscious or seriously ill, there is some family member who sees them once a year that comes in and changes things and makes decisions that the patient has verbalized that they never ever wanted.

personally, I think there is a special place in hell for people like that.

agreed. we see this a lot in my unit. the patient is end stage something or other, on CVVH, and on their last breath...but yet, that ONE family member who doesnt visit but CALLS once every few days to check in, still wants 'everything done'.

so yes, once a patient goes into the OR at my facility, their DNR is null and void and they become a full code from the beginning of the OR time to...i wanna say something like 24 hours after? and the DNR documentation needs to be rewritten.

thanks for all the input!