DNR versus AND - page 2

by Ashley, PICU RN 4,055 Views | 18 Comments

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 important because when parents... Read More


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    We use AND in my children's hospital (I work NICU). AND can mean a variety of things and when our docs sit down with parents, they clarify things and parents get to choose what they want/not want done, like no CPR/CV meds, intubation, blood products, labs, etc etc. On each shift, the off going nurse brings up the document on our powerchart so there's no confusion. And of course, a parent may revoke it at any time.

    I think it's great. We need to get away from this culture of the negative "Do Not Resuscitate." I feel like the public is so scared of death and this does not help things, with the picture in mind that we are not helping their loved one or themself.
    Ashley, PICU RN and wooh like this.
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    I understand the comments about the differences between the terms DNR and AND. However, the unique aspect of pediatrics is that our patients who pass away on our unit very often have chronic illnesses (genetic defects, histiocytosis, autoimmune disorders, neuromuscular disorders) that will eventually cause death no matter what we do. The choice becomes when we stop managing the disease and start managing the symptoms. By the time we reach end of life discussions, it's when we've exhausted our medical options and they just aren't working anymore- like our oncology patients who have completed all the chemotherapy courses, radiation, surgeries, etc. and the cancer isn't going away. Or, it's a condition that's just going to get worse no matter what we do- such as SMA. There aren't too many situations where it makes sense to continue aggressive treatment without coding because we know the patient with either 1. never be able to get off the ventilator or 2. never recover despite our best interventions.

    AND also allows for great flexibility of interventions- because the goal is providing comfort. Antibiotics, diuretics, feedings, BiPAP/O2, even palliative chemo or radiation can be included. But at the same time, if any of the above are uncomfortable for the patient or causing increased stress, we can stop them.

    Just DNR or DNI has it's drawbacks as well. It is truly all about education, but the problem is when your doctors are not able to explain end of life in terms the parents can comprehend, it can create problems. For example, we recently had a patient with a genetic disorder who had been in and out of the hospital frequently. She was having increased respiratory distress over the weekend and her condition suggested the intubation was indicated. But the mother, who had spent lots of time in the hospital with her daughter, didn't want her intubated. However, none of our doctors were adequately able to explain the ramifications of that decision- that is was possible that eventually her daughter would get tired of working so hard to breathe and her body would give out. So even though the patient was a DNI, she was not a DNR, because the mother still wanted treatment and, like many parents, was equating DNR with not treating her daughter's condition with all of our best interventions. . We continued to treat aggressively, but in the early morning she went bradycardic and eventually asystolic. We ran a full code on this child but we were never able to get a perfusing rhythm back and she died. Could this situation have been prevented, and the child allowed to pass away naturally, with greater comfort and less pain, if there was greater education about AND versus DNR? I think so.
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    And we will call patients clients instead too....I dont see the need for all this verbage.
    SoldierNurse22 likes this.
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    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.
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    The 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.
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    Quote from phil1968
    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.
    You 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.
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    I 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.
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    Quote from noreenl
    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.
    I'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.
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    Clarifying 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!
    JustBeachyNurse likes this.


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