DNR orders

Sounds like we need a bulletin board for "doctor education"! In my opinion, that doctor was just glazing over a subject that needs to be handled more tactfully, but he probably felt like he "covered it". If it happens again in the future I might approach the doc and very deferentially imply that you overheard the conversation and it sounded as if the patient did not understand him. Sometimes that has worked in the past. However, it is not only docs who can broach the subject of DNR status and if you feel that a patient was not given adequate info to make an informed decision then you have every right to approach that patient and clarify things. This way the patient can bring it up again with the doc if they feel inclined to do so.

I am meerly a student nurse but in my clinical preceptorship in an ICU I have had the oppertunity to witness this problem a number of times. I witnessed nurses not feeling empowered enough to be an advocate for their patient. I was shocked that the nurses did not delve in further with their patient's about thier DNR status. They were able to talk about it amongst themselves but never confronted the MD with thier concerns. In nursing school I have been told over and over that we are autonomous and our job is to be a patient advocate. It was upsetting to me to see that sometimes nurses feel subordinate to MD's and they let that affect their patient's experience. I would love to hear from empowered nurses and their feelings about the subject of DNR orders and from those who feel like they can't approach some docs and why. Thanks

I couldn't help but respond here. I have made myself quite a nuisance with those above me (Nursing Mgt., MDs and case managers) on precisley this topic. My unit care for a lot of extremely elderly patients or those with multiple morbidities to complex for home care. I came on the other morning and got report on a 98 y.o. lady who was bleeding from the rectum overnight. Her diagnosis on admit orders and on the kardex, was anemia and dehydration, and she was a full code! Are you worried? I was. I did a chart review on her, because I just could not see myself and the other nurses performing a full code on a extremely sick, extremely fragile woman. There was nothing more to be gotten from the chart. She was transfered to us from another unit and I found her old chart, which did have her H & P. Turns out she had a massive CA mass iin her colon, the family had decided on comfort care, the patient was not told her diagnosis on request from her family (pt had some dementia), and still NO DNR! The MD did not take the time to fill one out. No signed DNR in the chart means full code no matter what anybody has charted! I tracked the MD down and got the appropriate paper work done, but can you see the amount of time and energy this took. Can you imagine the trauma to that old lady if in her last minutes of life a code was called on her.

Unfortunately the above example is very common. People are uncomfortable, especially MDs, to discuss end of life decisions. But to be the holistic, patient centered nurses we trained to be, we must discuss this. I have found that my patients almost always know exactly what they want done, or not done to them, and most I glad I care enough to ask.

Please make this a part of your practice!

Naomi, RN

This is from a prospective future patient. I know I would appreciate being educated about my health care options....I know nurses are loathe to step in often times. BUt man oh man..docs seem to think just because they know what is going on everyone around them will absorb it by osmosis. Much of my understanding has come by observation when family and friends have been in hospital. AND I find some of what I thought I knew was WAY wrong.
Personally I would notify nurses that for my own reasons I need the DNR/DNI sheets in my chart and at my bed. ( I am not that much in a hurry to leave this life.....but things happen and life on a ventilator is not my idea of one.)
As best as I understand..if my heart stops there will simply be no effort to restart it..same if I go into respiritory failure...both seem like fairly quick ends....far quicker and easier than some I have been present for.

I am an RPN in Ontario and code status is part of our admission process so when I do an admission I am able to explain exactly what a code entails. This enables an informed ecision by the pt.

Speaking only for myself, WHENEVER possible, I try to be in the room when the doctor explains DNR to a patient. So after the doctor give a short and very informal explanation, I jump right in with the physician present to explain in detail what DNR means, what is doesn't mean. What we would do if she was a full code in the event that her heart stopped and she stopped breathing etc... I make sure they understand DNR does NOT mean do not treat, if they have a teatible illness. Most elderly do not want all that done to them.

If I can't be there when the doctor is, I will go in a casually bring up the DNR, ask the patient if they have any questions, which they usually do. And I answer them honestly. I've found their biggest fear is will they be kept comfortable. I assure them we will do our best to see that they are comfortable.

I usually end up having to call the doctor, and get a new DNR form.

I'm not pro DNR, but lets face it, no one lives forever, I believe in dying with dignity, and I also believe in giving the patients the hard facts, so they can make an informed decision.

What if a patient who is DNR is resuscitated and is brought back to life? What is the next step or what usually happens when this occurs? Just curious.

If that occurs, they are then treated like a living person, until either they themselves are awake and alert enough to say "STOP", OR Family steps in and says "No more".

Then if they are intubated, the decision might be made to take them off the vent and let nature takes it's course, OR if they are not intubated, they go about their lives, and if they stop breathing or their heart stops beating, nothing will be done - but they must have a DNR on file with their nearest hospital, post one on their refrigerator, keep one in their wallet - just in case