Chest Pain and DNR status

[MissRN7]

Hello All,

I am a new grad, I want to know what is the general rule for DNR residents who isexperiencing chest discomfort? The nursing policy at my place does notinclude any info on this. Do you call the health proxy if they want to reverse the code status?

Thanks, I would appreciate your input on this matter.

[Anne36, LPN]

Did you know exactly what their status is? Where I work there are levels, from 0 (no interventions) to status 4 (full code). If someone has a DNR, that could just mean do not give CPR, it does not necessarily mean you wouldnt give Nitro. Look more closely at the wording of their code status. I did have a status 0 client whose daughter I called to tell her about loose stools, possible C-Diff, signs of dehydration, and she approved a stool culture, antibiotics, and IV fluids.

[akulahawkRN, ADN, RN, EMT-P]

It very much completely depends upon the wording of the "no code" or DNR and facility policy. If I were given a DNR patient with chest pain/discomfort consistent with MI, I would follow the MONA protocol. Why? My goal is symptom relief, not necessarily preventing a code. That might even include taking the patient to a cath lab or pushing a thrombolytic. A DNR patient in shock might get fluid or blood, but not likely pressors.

Just remember that DNR doesn't automatically mean "do not treat." It just means not to resuscitate using (usually) specific modalities. You will have to research what your facility determines what is considered symptom mitigation and what is considered resuscitation for purposes of a DNR order.

Until otherwise told, I generally consider a DNR to mean: No CPR, No intubation, no assisted ventilation, no pacing, no cardiotonic drugs (aka no pressors), no defibrillation/cardioversion. All else outside of those things are ok to use... unless, once again, your facility has other specific orders for what "DNR" means there.

[sapphire18]

DNR stands for do not RESUSCITATE. So technically it shouldn't even come into play until the pt loses a heartbeat or stops breathing, at which point there is nothing you can do. It does NOT mean no antibiotics, no pressors, no surgery, etc. (Although in my experience pts become a temporary full code while in surgery. This may not be the case everywhere, idk.) You should try to prevent the pt from "coding" (dying, since there is no code with a DNR). If a pt is this sick you should try to know goals of care ahead of time; of course, this can't always be done. If you don't know, it is better to err on the side of too much rather than not enough treatment.

This is why I have encouraged my family to create living wills, lol

[BrandonLPN, LPN]

"chest pain" could mean many different things. Musculoskeletal pain. Chronic angina. GI upset. So, you must first figure out what's going on. You still treat whatever it is. A majority of LTC residents tend to be no code. But we still treat pain and disease symptoms, right?

[MissRN7]

Yes we do treat in LTC.

[MissRN7]

Thank you all this was really helpful!!

[NamasteNurse, BSN, RN]

we do a little investigation to find out what the pain might mean. is it heartburn? true angina? a bellyache? treat the symptoms. most cardiac pts have nitro prescribed. all DNR means is if they are full on dead, you don't do CPR. Everything else up to that point is treated. treat the symptoms. even if they pass out you give O2 and try to revive them. that way you can always feel good about saying "we did everything we could". but def check with your supervisor, or DON for specifics at your facility.

[DSkelton711]

We have 2 code statuses where I work: DNR (heart quits beating-no intervention. Treat everything else) and Full Code (CPR and call 911). Chest pain is not death.

[rlev]

My take on DNR is if you were to walk in on a pt who has clearly stopped breathing and has no heartbeat then you would let it be and call the family. Otherwise, treat, treat, treat. A lot of our medical treatment relieves symptoms and alleviates suffering, not necessarily life saving. Err on the side of caution. I once had a nurse tell me we made a mistake putting a patient who was having very difficult time breathing on bipap because she was a DNR. I said she didn't code and she didn't stop breathing, she had severe dyspnea and we eased it with the bipap. She and the family were able to make a better decision about what she wanted and needed if this were to happen again.

[eatmysoxRN, ASN, RN]

I'd get an order for nitro and treat it like I would anyone else with chest pain. I wouldn't sit there and let them have cp or a MI that nitro or morphine could have prevented. A DNR is only relevant to me if the patient requires a code. Otherwise I treat them just the same.

[CapeCodMermaid, RN]

It's amazing to me that these questions still pop up here. No wonder families are unsure of what DNR means when nurses themselves haven't a clue.