CPR and DNR Orders

Tweety, BSN, RN · Nov 27, 2004

I agree that at any time during the hospital stay a patient can rescind his DNR order and you have to code them. Obviously the patient was alert and oriented and maybe in a panic state, I would assure the patient that DNR did not mean "do not treat" and try to calm him down, but if there was no time and he suddenly became unresponsive after recinding then I would call the code.

How about this situation. Patient has a living will and it's very specific, but it also names a family member to speak on his behalf when he becomes unable to. Can the family member recind the DNR order?

Antikigirl, ASN, RN · Nov 27, 2004

Can the family member recind the DNR order?

In my state yes, but it has to be the spouse or immediate family member (which can be tricky and needs clarification..I mean, I have had daughters/sons ask!).

I had a man down and was unresponsive but breathing...the family was screaming at me NOT to do anything. I explained the fact that a person must be pulseless and not breathing for me to do nothing and they just didn't get it..I just positioned him on the floor for CPR if necessary..that is all (and they called me in!!!! What was I suppose to do...hold their hand and say last rites???? AND they called 9-11!!!!!!!UHGGGG!) I finally I said..

"According to my state law, my lack of action can be construded as neglect and thusly if something goes wrong MURDER, and I am sorry it comes down to a piece of paper, but that paper saves us medics from making poor choices with people own LIVES! In these situations and I have to abide by the rules. He is alive, and I am just going to try to help him stay that way..but the second he is not breathing...I will most certainly stop...so wish for that if you want, but in the mean time just get out of my way and let me do the job I was hired to do for your father!!!".

He lived, and got to see the birth of his second grandchild before he finally did pass. The family thanked me for not listening to them..that they felt "GOD" made sure the DNR papers weren't to be found so he could see his little grandbaby before he left. And yes, they got a DNR on paper and had it handy after this...and I sat down and explained it IN FULL to them...even about the term LONG TERM IV..they understand it well for their mother who is still with us at our facility. It took a very emotional and sad experience for them to come to terms with this piece of paper and a medics role in it...but at least there is one more family that understands it...and that is how I do it..one family at a time! :)

And the reason that a family member can not charge the DNR on scene is because one..it isn't the patients wish per say, two..they may not have the patients best interest in mind (I have folks waiting for their loved ones to die so they are no longer a financial burden..sad but true....).

TennRN2004 · Nov 27, 2004

I'm not sure, but I think states have different rules regarding this area and nurse practice acts. I know this very issue occurred on my unit several months ago. We had a patient who suddenly started hemodynamically deteriorating very quickly (no bp, brady HR in the 40's) and he had been a DNR for some time. The wife at the bedside on the floor where this started starts yelling hysterically for something to be done.

Well, the nurse of the patient did what someone else said and called both the nurse supervisor and the nurse manager at home. The nursing supervisor came up and said to start a Dopamine gtt on him and take him to the ICU. Both of these without a physician's order!

Well, he comes up to our ICU and we're freaking out because we know him from multiple admissions, know he's a DNR, and none of his doctors know he's been transferred to us. Bottom line, when we called the doctors to inform them of the events they both clearly stated "what you're doing is illegal, you're practicing medicine without a license, and we will not change code status."

They both also said to turn off the Dopamine stat and do not attempt any type of coding activities, wife yelling at us to do it or not. They talked to her and explained again why he was a full code and that legally they were covered for not allowing her to change code status.

Now this patient was full blown AIDS, history of several types of cancer, terminal patient for many months, many, many in depth medical problems. I'm not sure if not reversing a DNR stands in every case or just in situations like this one where the physicians stated any attempt at prolonging life was futile. However, if there is a terminal patient with less than 2 weeks as the OP mentions (not sure if this was just an example- an arrest pt talking? : )- but I would think the same type of attitude from the doctors may be prevelant. Of course, I can't tell you how many pts we've seen with less than however many months to live, come in the hospital sometimes a year later looking and feeling great. Ya just never know.

I would definitely investigate this in my area for those of you working in areas where this is a possibility that could occur.

suprnurs40 · Nov 27, 2004

The actual scenario is this: 76 year old woman suffering from incurable brain tumour. Informed opinion said that she would die within two weeks. With her consent, a DNR order had been placed on her chart. One afternoon, this partially conscious patient patient grabbed the nurse's arm and and began mumbling, "I don't want to die. Please don't let me die." She lapsed again into unconsciousness and quickly began to arrest. Remembering the DNR, the nurse let the arrest take its course, and the lady died. So, should we always resuscitate if there is any question about the patient's continued consent to a DNR order, even if resuscitation continues to be futile? I need your opinion!!!

RNKPCE · Nov 28, 2004

What if a patient is a DNR on her living trust and she also has a adult child as "Durable power attorney for health care". Her baseline is mild to mod dementia. She is in her early 90's and admitted talking, tells us why she is admitted, says she is at home instead of the hospital, but the adult child changes her code status to full code. Something about this just didn't seem right. The doctors had an order for full code on the chart but the living trust in her chart said no code.

I pray that if I am a DNR that my family member does not change me to a full code.

By the way the family member that did this was a lawyer.

TennRN2004 · Dec 3, 2004

What if a patient is a DNR on her living trust and she also has a adult child as "Durable power attorney for health care". Her baseline is mild to mod dementia. She is in her early 90's and admitted talking, tells us why she is admitted, says she is at home instead of the hospital, but the adult child changes her code status to full code. Something about this just didn't seem right. The doctors had an order for full code on the chart but the living trust in her chart said no code.
I pray that if I am a DNR that my family member does not change me to a full code.
By the way the family member that did this was a lawyer.

I have seen this scenario happen as well. A 94 y.o. pt who had quite clearly in his living well he wanted to be a DNR as well, no intubation, no CPR. Well, the family changes code status when he's admitted, he ended up intubated for 2 weeks, and only when the doctors start talking to the family about a trach if they were adamant about keeping him a full code, they finally relented to a terminal extubation. How terrible for the patient though. He suffered through two agonizing weeks, and then all the family is at the bedside crying and saying they're sorry to see him suffer so much. I don't know how to make family's see sometimes the best thing is to just let a person die with dignity- especially if the patient has clearly made his/her preferences known about code status beforehand. It's so frustrating.