DNR-CCA vs. DNR-CC

[Cp42185]

This is a new topic that came up at work that I am

Curious what the rest of you think. My thought process is that a DNR-CCA means do not resuscitate, which obviously means no chest compressions at the time of cardiac arrest. But up to the point of cardiac arrest you'd treat the patient as a full code (pressers, atropine, etc.)

And DNR-CC is simply comfort care associated with hospice, terminal wean, etc. which just includes lots of morphine Ativan etc.

We have a doc that when the 48 hour wean process begins he leaves them DNR-CCA until the point of extubation after the 48 hours then they are switched to CC. By definition, would we have to give atropine and/or titrate pressure mess if they were tanking even if they were in the 48 hour withdraw window?

[marienm, RN, CCRN]

You're using some terms that I'm not familiar with. What does DNR-CCA mean? (Specifically, the CCA part?)

I'm going to assume DNR-CC means "Do Not Resuscitate-Comfort Care." At my hospital, this usually means "comfort measures only" and we would not use pressors to maintain life. We might use IV fluids gently, or oxygen for comfort. We would give morphine and ativan if indicated. Depends on the situation and the patient/family wishes. Patients are not automatically put on Comfort Care status "after a 48-hour window" so I'm not sure how that works in your hospital. They are made Comfort Care at the wish of the patient/family. If it will be a little while until the expected death, we put in a Hospice/Palliative consult and usually this team manages their care from that point (instead of their original team). If it is a patient who is declining rapidly, we could terminally extubate (when the family makes the decision), stop all pressors and fluids, and do post-mortem care all within a few hours.

We have patients who are DNR but NOT DNI (Do Not Intubate)...so they could be DNR and we would not do CPR/ACLS drugs, but we would intubate if needed and/or they are already on a vent/trached. DNR does not mean do-not-treat (that's what Comfort Care is for) so we would absolutely give pressors, insert central lines, etc, on a DNR patient if indicated and if the pt/family consented. I have had a situation where we gave atropine to a DNR patient for extreme bradycardia...however it became rapidly apparent that they were now in PEA and we did NOT give more drugs or do CPR.

[smf0903]

I'm not sure if criteria varies from state to state but for us DNR-CC is comfort measured only. DNR-CCA we will do everything up to the point of cardiac and/or respiratory arrest. We can intubate PRIOR to respiratory arrest, however I have yet to see a DNR-CCA order come through that does not specify "no CPR, no intubation". The doctors that we have who address code status are very good at specifications. We have orders come through for no dialysis, no pressors, etc on the order.

So by our state's definition, yes pressors and such would be given if the patient is still technically a CCA...unless they lose a pulse then that's the stopping point.

[MunoRN, RN]

What do you mean by a "48 hour wean"?