DNR care questions

bluegeegoo2, LPN · Feb 28, 2019

My personal policy is "You might die, but you're not gonna die here." (Never, ever, EVER said out loud, for the record, and of course does not apply to hospice patients.)

Unless a DNR also has a DNH (Do Not Hospitalize) in place, out they go if it is their or their POA's desire.

If either decide that they are not to be sent to the hospital, I will document my butt off in a very detailed manner. Names, times, MD notification of resident/POA wishes, verbatim quotes, etc.

You may also want to ask for clarification with your management team.

CoffeeRTC, BSN, RN · Feb 28, 2019

They should have a POLST form or advanced directives

https://polst.org/polst-and-advance-directives/

The old "when in doubt, send them out" is a thing of the past.

DNR doesn't mean, don't treat. The polst will be more specific on what the resident wishes are. Do they want IV fluids? Antibiotics? Comfort measures? When 911 and they is no advanced directives or original paperwork they will normally assume CPR.

Early detection of changes is key. If you can act on that and get orders in place that is the goal. Most LTC residents with DNRs in place would want to be comfortable in their own home and have a peaceful passing.

Our facility is equipt for IVS and pain management with our emergency supplies. Labs and Xrays can be done in house.

Golden_RN, MSN · Feb 28, 2019

Of course, each clinical situation is different, but here are some things I keep in mind:

1. Check POLST or similar orders (Are they comfort care? Is the change in condition expected? etc.)

2. See if the physician has deemed the resident able to make his own decisions or who the responsible party is

3. Keep in communication with the physician

Glycerine82, LPN · Apr 14, 2019

DNR simply means if their heart stops you don't give CPR. If they need intervention, you do it.

If they are comfort measures/hospice it all depends, but in general just because a patient is a DNR doesn't mean they want to die or don't expect us to take good care of them.

guest825264 · May 9, 2019

I wanted to thank everyone who responded to my question. I read all of your responses and have put them to work. I have had to handle 2 deaths with DNR patients and have been able to respond effectively and responsibly!

amoLucia · May 10, 2019

Am reading this late, but just to add a comment to OP -

Whenever I learned of a sudden decline of a DNR pt (either I determined the decline or it was reported to me by the preceding shift), I always wanted to know that the family was aware of the change and if they wanted to visit soon.

I hated to make that awful phone call at 3am to tell them of a pt passing. Even if a death was expected, I gave the family an opportunity to make that one last visit while the pt was still alive. There were some families who had prepared for the passing, and they declined to visit.

Their choice - not that 'they didn't know' or 'why didn't someone call?'

ALWAYS, ALWAYS keep them in the loop. That might be difficult as sometimes I might call an offspring instead of another elderly spouse.

Somewhere in the communications, I would try to GENTLY remind them of the DNR. Also to reiterate that we would be doing everything to keep the pt comfortable and involved in personal and community ADLs. I'd check about involving religious practitioners of their faith if desired. And I would GENTLY, EVER SO GENTLY question about their selection of a funeral home (if not already designated in the chart record).

My purpose was to express to family that the end was probably very close and now would be the time for them to alert other family and to close up loose ends.

Every family was different and determined how I proceeded. Being tactful was paramount and to be reassuring that the pt would be cared for as best as poss.