DNR versus AND - page 2
We all know that DNR stands for Do Not Resuscitate, but the move in my children's hospital is to try to switch our terms from DNR to AND, which means Allowing Natural Death. The verbiage is very... Read More
Jun 18, '12Janfrn, is there any way possible to make that system-wide module on "goals of Care" available? it shoulds like your facility is on the right track when it comes to end of life care.
Jun 18, '12The big thing I see is that people don't talk about death at all until someone's so sick they can't make their wishes known -- not a 20 year old that gets hit by a truck, but the 80 yo with end stage everything, mets'd CA, etc. I think the whole AND (and I like that term) discussion should start when person has a serious diagnosis, not when they're agonal and will never live the 10 feet to roll their bed out of their ICU cube on the way to a hospice room. We did a study of which of our docs do referrals and how long they were with hospice before they expired. Some of the renal docs are good about hospice referrals early, and one pulmo doc won't refer them unless the family insists.
There are some people who are so terrified of their own death, they can't discuss someone else's.
Jun 18, '12Quote from phil1968You would think oncologists of all doctors would be comfortable with discussing this. Of course even to them "death" is considered a failure. I agree communication is key. I wonder if it could be gently done to send the docs to a therapeutic communication class or find out why they are so afraid of speaking of the dying process with their patients. Or even having Hospice do a inservice. I guess there is no easy way to combat the problem.I really like the idea, but I think the real problem is communication. I work on an oncolgy floor, and some of our oncologists will not talk about hospice or comfort care untill the pt is in the throws of death. Hospice is such a wonderful service, but it is nearly useless whe someone is mere hours from death. Physicians do not want to talk about end of life issues. I have been put in a position too many times of having to have this discussion with the family about their loved one who is just about to die, trying to figure out do I need to send them to ICU or not. All because their doctor would not talk to the family.
What we really need is a better dialogue with patients and families.
Jun 18, '12I find in my unit we use AND when withdrawing care. We had a patient today being withdrawn on and his code status is listed as AND. I have never actually seen DNR on my unit but we have "limited code" status where it is written out exactly what the parents want/don't want. We have another little guy on our unit now who is no chest compressions/no epi and no invasive procedures (ie chest tubes), but we are still supporting him on the vent/milrinone/iNO until his parents find the " best" time to withdraw though they are fully aware that he will not recover.
As far as approaching the parents like others have said some doctors are better at it than others. I will say though that the doctors in the Cardiac ICU where I am now verses the NICU where I was before are MUCH better at telling parents that there is nothing left they can do and that the child is going to die. They seem to be better at taking that responsibility out of the oparents hands whereas in the NICU babies with fatal defects (no kidneys/hypoplastic lungs for instance) would suffer on for days full code and having multiple interventions done with the doctors never really telling the parents they baby wasn't going to recover.
We also have a great palliative care team in my hospital. Unfortunately it is RARELY utilized in either of the ICU's I have worked in, I'm not sure how well they are used in the PICU. It's a shame really because they offer such good services and support for parents and families that they need.
Jun 18, '12Quote from noreenlI'm not so sure we're actually ON the track. The track has been laid but I'm not seeing any trains moving along it. I'm quite positive that the Goals of Care module is copyrighted by the health system I work for; that entity is extremely paranoid and jealously guards its "property" as if it were platinum-plated! There is a link to it on the web, but to actually get to the modules (peds/adult) one must log in through the eLearning portal - using their ePeople log-in. There is access through a non-employee link but they want a lot of personal information before they allow you to see it.Janfrn, is there any way possible to make that system-wide module on "goals of Care" available? it shoulds like your facility is on the right track when it comes to end of life care.
Jun 25, '12Clarifying DNR vs AND
I am a peds palliative care RN at a unique house in northern California. Our standard of care uses AND exclusively because it is the preferred terminology now in the practice. The cool thing is that in California and maybe elsewhere, the palliative care teams are promoting the legally recognized form POLST--Physicians Orders for Life Sustaining Treatment. It is a hot pink form that very clearly defines the parents/child's/adult's wishes to all medical personnel who encounter the patient. Parents keep several originals with their child at home, school, car etc in case of any sudden medical decline. Has been a God send to our families who want some interventions (i.e. blow by 02, oral antibiotics) but not others (IV meds, chest compressions, intubation, vents).
Thanks for the great question and request for ideas. Love this site for all the great professionals who share thoughts!