Again..Problems with the Comfort measures Only Orders

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:angryfire

I am working in a pretty nice little facilty, where I have always felt that the DON and I were on the same page. Well, we have a new director now and the first day I worked with her was Monday. She is a straight-forward, nurse who seemed to know long term care well. We got along fine most of the day. That all changed when one of our residents went bad. (Difficulty breathing, low pulse, low pulse off, low BP.) The patient is CMO. My director said she did not like CMO orders and wanted to send her out. I have always believed in CMO, and get upset when people get sent out to die in the hospital instead of their "homes."

I said "she is CMO. her family does not want her sent out." She replied, "That is not what CMO is referring too..it refers to a long term illness not a sudden change in condition" WHATTTTTT????? Please, am I losing the few marbles that I have left???? Am I supposed to send out every CMO in Resp. Distress? Where will it end?? Sorry so long

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CMO doesn't change with change in condition. That is the whole idea. The family and patient no longer want anything done. Perhaps your DON doesn't like expirations to show up on her board, and prefers transfers out only?

I hope that no one ever treats her the way that she is trying to do to others. Is she then going to be responsible for their bills?

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an abrupt change in pt. status wouldn't warrant cmo as a first resort. they're typically implemented after either a dx w/advanced terminal ca or a steady decline in function and health.

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What I have been taught is DNR does not mean do not treat.

Same with comfort care. Was this change part of the natural progression of her illness, such as NPO due to asperation and the family refused a feeding tube that then progressed to dehydration, with vs steadily dropping or was this some one who was fairly stable with a sudden change? In the first case, definetly do not send to the hosp she would simply be rehydrated to start the progress again. The second one may get her on ABT. Maybe its simply a UTI and even hospice that I have worked with says no one should die from a UTI.

My understanding is this must be taken on a case by case basis. Very, VERY difficult decision making IMHO.

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funny this should be on the board, i just had a similar experience sunday, actually monday morning 2 am. i work ltc. i have a chf patient, who is up and down, one day you think, well this is it, the next day he's alert, oriented, requesting to take a shower. he's been back and forth to the er numerous times. code status: dnr. to me that does not mean do not treat as well. he's extremely hypoxic. family very supportive and concerned. of course, lung fields very congested, bp wnl, o2 sat room air 70%, o2 @ 2l/nc 90%. his 02sat dropped on me, filled up quick, frothy mouth, requesting to see his wife, hallucinations, telling me he was dying today. doc didn't return call, house doc called with order to send to er. he was never admitted his doc seen him monday in er sent him back with comfort measures only and not send him out again. we didn't have that order to begin with. that's what is unclear to me, yes i understand dnr and i understand comfort measures only.......but i don't feel it's made clear by the doc's what they want us to do. this doc wasn't mad or anything, but if he would have returned my call he could have told me, don't send him out, etc. he did come back with an end stage dx...........i'm just really confused about all that. i'm never sure exactly what to do. my don also told me to send him b/c staff has to notify her when any pt goes out to er.

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I hate to be the one always beating the drum about rules/regulations and policies/procedures, but this is a great example of why your facility (all facilities) needs to have official, written policies/procedures, approved by the governing body, defining exactly what DNR and CMO orders mean in your facility and how they are to be implemented. And then staff need to implement them as written (or raise the question of changing the policy).

This is exactly the sort of thing that should not be left up to each individual person's opinion. It's a darned shame that your new DON "doesn't like" CMO orders, but that really has no bearing at all on the situation. It's not her call to make.

I work as a state and federal inspector/regulator for acute hospitals (there's another team in my agency that does LTC), and I can tell you that, if something goes wrong and a family ends up complaining to your state agency, the inspectors who investigate will be looking for your (facility) policies & procedures that apply to the situation and whether or not staff followed them. Not having such p/p will not help the facility ...

PS, laughingfairy -- DNR means "do not resuscitate," not "do not treat anything" ...

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[quote name=elkpark

PS, laughingfairy -- DNR means "do not resuscitate," not "do not treat anything" ...

I'm sorry if I was not clear. That is what I meant. We have a number of docs and/or families who want to treat it that way. We have had the hospital send people back with little notes or on the discharge instructions. "pt is DNR DO NOT send back to hosp" and I mean residents who have gone into resp distress, change in mental status post fall, etc. Emmerging (sp) conditions that should be treated, totally unrelated to the DNR or comfort care orders.

I want to scream at them somedays "YOU MEAN my Resident who walks, talks, A&O x3, but has had the foresight to be a DNR, because that is what she WANTS, if she is found DEAD CANNOT get treatment in your ER for a fx, resp distress, etc?"

Granted the ones that they act like this with usually are chronically ill, not the walky talky type. But it is the same thing. And that is what I personally find so frustrating. Drs and families who decide to have "DNR" "Do not hospitilize" or "Comfort care" and seem to think that everything is just done, that we has health care providers should not even attempt to fix, fixable things like UTIs, pneumonia, chf, etc.

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funny this should be on the board, i just had a similar experience sunday, actually monday morning 2 am. i work ltc. i have a chf patient, who is up and down, one day you think, well this is it, the next day he's alert, oriented, requesting to take a shower. he's been back and forth to the er numerous times. code status: dnr. to me that does not mean do not treat as well. he's extremely hypoxic. family very supportive and concerned. of course, lung fields very congested, bp wnl, o2 sat room air 70%, o2 @ 2l/nc 90%. his 02sat dropped on me, filled up quick, frothy mouth, requesting to see his wife, hallucinations, telling me he was dying today. doc didn't return call, house doc called with order to send to er. he was never admitted his doc seen him monday in er sent him back with comfort measures only and not send him out again. we didn't have that order to begin with. that's what is unclear to me, yes i understand dnr and i understand comfort measures only.......but i don't feel it's made clear by the doc's what they want us to do. this doc wasn't mad or anything, but if he would have returned my call he could have told me, don't send him out, etc. he did come back with an end stage dx...........i'm just really confused about all that. i'm never sure exactly what to do. my don also told me to send him b/c staff has to notify her when any pt goes out to er.

it sounds like they want this patient to be a dnh and if he decompensates again, to keep him comfortable. there's nothing they can do for him in the hospital if he's a dnr. and there's nothing you can really do to treat it either. in advanced chf, his pump is critically impaired. it's time to get in writing a dnh order. they can try the o2 and diuretics at facility but inevitably he's just going to slip away. as a nurse, you can make it peaceful for him and the family.

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Comfort measures means keep the pt comfortable only. Pt needs a DNR/DNI/DNH order specifically documented so the pt is not sent to the ER, not intubated, and NOT resusitated if found expired and advance directives by the pt or POA need to be specified, documented and followed. By comfort measures they specifically mean yada, yada, yada.

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A patient is his/her advanced directives can stipulate what they want done or nor want done. This is not the same as a DNR order. They are two completely different things.

Comfort measures only usually mean no blood draws, etc., especially if the patient/client had previously documented that they did not want them.

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an abrupt change in pt. status wouldn't warrant cmo as a first resort. they're typically implemented after either a dx w/advanced terminal ca or a steady decline in function and health.

This has always been my understanding/experience with "comfort measures only".

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Pt needs a DNR/DNI/DNH order

Sorry; I'm an American, but I don't KNOW about the DNH...WHAT is a DNH,please? Do Not Help? Do Not Hassle? Do Not Harangue?

Do Not Hope?

Confuddled, Spiritus:imbar

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