Confused about my role....

[Virgo_RN, BSN, RN]

I'm an LPN in a hospital setting. I work independently within the bounds of my scope of practice. When anything comes along outside my scope, I involve the charge nurse.

I am a bit confused about my role in the care of the dying patient whose family is not ready to declare them a DNR yet.

A little background: I recently had a little old lady in my care, who was very sick. I've seen enough death to know that she was heading that way. It was only a matter of time. Yet the family still had her as a full code, and we were doing all sorts of invasive things to this frail little body that was ready to leave.

I knew she would be circling the drain on my watch, and the last thing in the world I wanted to do was chest compressions on that frail little body. Fortunately we were finally able to convince the physician that she needed to be in ICU before that had to happen.

I didn't say anything to the family, as I felt that was the doctor's role to discuss the patient's prognosis and code status, and that I would be overstepping my professional boundaries by saying anything.

However, I just feel sick over the whole thing, and I wonder what I could have said that might have made a difference but wouldn't have been overstepping.

[Tweety, BSN, RN]

I think you did the right thing. Sounds like they wanted everything done.

There have been a few times that I found it appropriate to tell families that we (nurses and doctors) were going to do everything we could, but what did they want done if the patient quit breathing or went into distress enough to need a ventilator/breathing machine. I usually just throw it out there for them to think about "you don't have to answer now, but you need to talk to your siblings about what you would want if..........".

It's a delicate area, and I try to affirm that I'm not the one to predict or diagnose, but just need to know their true wishes, or if they want to reconsider a previous statement that all be done, etc.

[pagandeva2000, LPN]

I agree with Tweety. I think that it is really the role of the physician to initiate discussion on the plan of care and diagnosis with the patient and family. Gently asking them what they would do, or reconsidering is a sensitive issue, one that take experience to venture into. If the family seems as though they would be accepting to your suggestions (in many cases, we know), then, consider to do so, but for now, I would take it to the RN until I felt more comfortable.

[rogue medic]

My first job was as a Hospice nurse, so when it comes to death and dieing i feel really comfortable about talking about it. As this is my patient I feel that it is my responsibility to make sure that I take care of ALL aspects of their care, and that would include talking to the family about it. After moving from hospice to a tele unit this has come up often, and i have found the best thing is to touch base with the Dr and let them know of my concerns for the pt and if they are going to talk to the family. After that i touch base myself with the family. Docs look at things from a diff angle then we do and frankly i feel that we as nurses approach this topic in loving and caring side of the job. Docs can come across as work like at times. We spend alot more time with the family and the patient so dealing with them and coming across in a manner that lets them know that we are asking a tough question but its out of our caring for them and their loved one.

[Virgo_RN, BSN, RN]

The thing about hospice is that the decision to allow the person to die has already been made. In an acute care setting where the doctor has already had this conversation, has told the family the prognosis, and yet the family still wants us to do everything we can to save their loved one, is a different situation and much more difficult to know how to handle.

[Tweety, BSN, RN]

At that point then we just have to be supporitve of their wishes, even though we personally know it's an exercise in futility, it gives them some sort of comfort and closure thinking they did everything they could do. Not everyone is comfortable with DNR. My BIL's uncles gave him a hard time for "killing their sister" when she was made DNR?comfort measures only.

Maybe they have heard a story about someone who was told they were dying and then resuscitated and went on to live for years.

Sometimes I might gear it toward the patient "would you mother want to be on a breathing machine if she were to quit breathing on her own?" and see what they say. Otherwise if their mind is made up, we just have to be supportive of them, and be an advocate for the patients comfort.

[Rexie68]

I don't have quite the same scenario, but I understand your concern. I work in LTC and we have some 90 year old pts who are full codes. When I do the initial care plan meeting (yes, I'm an LPN who does MDS', writes care plans, and does the care plan meetings) with the family, I'm always sure to discuss code status and what that entails. When I explain the being a NO code in our facility means that we won't do invasive procedures and won't start CPR if their loved one is found without a pulse/resps. When the family understands that the patient will still receive quality care-antibiotics, pain meds, cardiac meds, etc., etc., -they usualy want to change the code status to DNR. The few that still want their loved one to remain a full code, for whatever reason, are informed that any acute change that the nurses think may lead to cardiac arrest will result in their loved one being sent to the hospital.

In the setting I'm in, it's the nurses job to speak with the families regarding these matters, especially since the physician is in the facility only once a week. The physician will talk with the family if necessary but he's responsible for 100 patients just in our facility, so there's no way he could keep up with everything, especially with all the admissions and discharges.

Upon admission, the social worker gets an original code status, and then we follow up. So many things that used to be only in the doctor or RNs realm are becoming important for LPNs to be able to discuss. Of course, you can always bump it up to the RN if needed!