DNR orders - page 5

by Erin

22,749 Unique Views | 53 Comments

After having once again witnessed a doctor ask a patient (this time a 91 YO) "if your heart stopped would you want us to do anything?" and then write orders for a full code without any further explanation to the pt of what this... Read More


  1. 1
    At our place DNR alone does not mean anything. We have to have CMO orders. It is unbelievable what can be done to people without coding them.. Simply put doctors have to learn to tell the 70-80 or 90 year old with multiple co-morbidities "sorry there is nothing more we can do." Every day we see the costs of health care soar because people have not talked about their wishes or those that have, there is an inevitable HCP that will step in and want everything done when the patient cannot speak for themselves. Is it because of the potential profit. Are MD's "helping" these people to earn some extra cash? I usually try to educate families and tell them sometimes the most loving thing they can do is let go.
    IowaKaren likes this.
  2. 0
    I remember an unfortunate incident involving an elderly man who had terminal cancer with mets to the brain and lungs. He was DNR, but while in hospital his respiratory status declined. Eventually, his ABGs deteriorated to the point that he became unable to make his own decisions, so his daughter who was POA made him a full code. He did code, and was on ECMO for a time. He ended up doing well, but when he was finally extubated he was livid with rage!
  3. 0
    If only patients could put a clause in the DNR forbidding family from changing 'the patients wishes' once they become incapacitated.
  4. 0
    I do not think that physicians should tell their patients that "there is nothing more that we can do" because that is by and large not true. What is true is that they are not likely going to cure them. They often can, however, do many things which will decrease the symptom burden and make the person more comfortable and functional. Unfortunately, physicians think primarily in terms of "fixing" whatever the disease is, rather than fixing the quality of life of the patient. This is part of the reason that many patients in hospice are happier and live longer than their peers with the same diagnosis' who remain in the traditional medical field. (a simple internet search will hook you up with lots of reading material on stats)

    It is helpful to be brutally honest with patients and family members who seem to have unrealistic concepts of what it will mean to them to have a "full code". Most will reconsider their choice when they hear the facts and truth about resusitation. There will always be a percentage who for some reason cannot make the DNR choice. What is problematic for me is that the evidence suggests that people/families/patients are making choices about DNR using incomplete and often incorrect information...the suggestion is that people are NOT getting the complete package of info regarding this important subject because some healthcare workers are uncomfortable with the info, with their role in the information process, with the interaction with sad families...for really quite a number of reasons. The bottom line is this....as health professionals we CAN impact these decisions by making sure to provide the involved parties with ALL of the facts, by not prettying things up, by advocating one patient at a time for death with peace and dignity.
  5. 0
    Since I work in a small Critical Access Hospital on an overnight shift I get few admissions but, since we are required to ask about Advanced Directives I use this opportunity to further explain (and ask that all-important question on their wishes). Our doctors are very good about then speaking to the patient and writing the DNR order.
  6. 0
    Does your hospital use DNR bands or any other DNR identifiers?
  7. 0
    Just out of curiosity, does your hospital use DNR bands? I'm a student nurse from California State Univ of San Bernardino and I'm collecting nurses' views about the use of DNR bands. Does your hospital use DNR bands? If so, is it effective? If not, do you think they would be beneficial.
  8. 0
    We don't use DNAR bands but we do have a DNAR form that is in the front of the patient notes on bright yellow paper.
  9. 1
    Since this is about education, I need it. I've been a nurse on a Med Surg floor for about 16 months. I've never seen a code. We RR patients and move them to ICU before they get to the point of coding. My floor also does oncology and we often get the pallitive patients. No codes for them either.

    So explain to me what a code entails the way you'd explain it to a patient. How is it different than what you see on ER or Grey's? I'd love to educate my patients on that, but I don't know. They didn't teach that in nursing school.
    CrazyGoonRN likes this.
  10. 0
    I explain what a full code means in detail. First, there are chest compressions. If the patient in question is elderly, I emphasize that doing chest compressions will almost certainly cause the ribs to be broken. Then there is intubation; I explain that a tube will be shoved down the patient's throat into the lungs so we can breathe for them. Then, there are medications that we can give, which may or may not help to keep the dying heart beating. Then, sometimes, we are able to shock the patient's heart to get it to beat more normally.

    I'm honest about the patient's chances of surviving such a thing. In most cases, (most patients who are at the end of life are quite elderly and have several comorbidities) doing a full code will allow the patient a few minutes or a few hours, possibly (in the best case scenario, although the patient will almost certainly be brain dead) a few days before death occurs.

    Of course I tailor my explanations to the particular patient. A very few people may only need a few defibrillations before we're able to get things under control, and that person may go on to live some more life. Most of the time, however, a full code is a futile attempt. It is (in my opinion) degrading to the person's body. The family is unable to hold that loved one's hand while life gently slips away. Instead, death is a fiasco and a torment.

    It depends on the patient, the patient's situation, and the patient's wishes. Too ofen, the patient's wishes are irrelevant: the family wants us do to EVERYTHING! I respect that. They don't know. So I do it. If grandma is 99 years old and full of cancer, but the family wants everything done even after I've described in detail what "everything" means, so be it. My one consolation is that by that point, grandma is too far gone to feel her ribs shatter.

    I also often have patients who believe that we want them to die so we can give their organs to other people. I try to explain that we wish no such thing, we don't have any incentive to give your organs away, but they've seen enough movies or read enough books to believe that this is what healthcare is all about. Fine. You're a full code.

    When an end of life situation occurs, it so often means the patient's wishes don't matter. Most people do not communicate with their family what they do or do not want done. So it's up to the family, who almost invariably choose to have everything possible done to "save" their loved one. I do not have a magic wand, but if they tell me to break their grandma's ribs, by god, I break their grandma's ribs. This used to torment me to no end, but I've come to peace with it. By then, grandma isn't feeling the torture anyway.

    Denial is stronger than love.


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