DNR- Do Not Treat?

Nurses Safety


Specializes in Telemetry.

What are your opinions on a patient who is a DNR? ---A DNR who is terminal, but not on hospice yet. On a regular floor.

We still have to treat DNRs. But recently I had one from the ED to my tele floor, septic shock, rapid A-fib, low BP. Nonverbal. Family said to call if anything happens.

Right- so all night I am calling MDs every hour and a half. cardizem bolus, dig bolus, cardizem drip on, drip off, NS bolus x3. Her BP varied from 82/48 to 106/54.

Then after her fourth NS bolus I repeated her pressure- it had dropped from 92 systolic to 68/42. HR 140s. Yes, her prognosis was the same. But it was happening too fast. I called a rapid response to get some help in there- it was clear to me she was going to die soon and I did NOT want that to happen before I could get her family there.

The point of this story- a lot of people gave me a hard time! They said "she's a DNR." and several people angrily left the room as soon as they heard she was a DNR. Mostly respiratory therapists and CCU nurses. I understand that, but it was so disrespectful- we have a moral, and LEGAL obligation to do what we can for our patients!

DNR doesn't mean do not treat. Or does it? Is there an unspoken understanding amongst nurses, such as the infamous "slow code" that we just ignore a DNRs decline? Being a new nurse- I now wonder if I don't understand the meaning of DNR. I wanted to come here and ask people with more experience.

What do you all think?

(ps- the pt's family made it in, and was by her side, was able to come to terms, and was with her when she passed away. so thank God.)

Specializes in Med Surg - Renal.

As far as I know, it stands for Do Not Resuscitate. .

It doesn't stand for Do Not Bolus, or Do Not Give Cardizem, or Do Not Give Dig, or Do Not Give Nebs,....

That being said, if you are going to call rapids for people with a DNR order, you better be real clear on what you want them to do for you.

Specializes in Med-Surg, Geriatrics, Wound Care.

I think I had a DNR that had additional information like DNI (intubate), no not treat hypotention or bradycardia, and no not call rapid response. I don't know if that is typical of all cases, but in this one, there were the separate issues. You could check to see if you have a specific DNR form that has the little bits and pieces about the specifics. I believe our policy is to consider everyone a full code unless the form is properly filled out, so it is important to check.

Specializes in Telemetry.

Okay, and if anybody disagrees w/ my decision to call the rapid please explain! i am trying to determine what the best action could have been- so in the future i wont be so stuck!

MN nurse, you have a point there- I should have been more clear there to the responders. I suppose I truthfully could have called the MD for the 7th time, but ugh it's tough sometimes to decide.

Specializes in Med/Surge, Psych, LTC, Home Health.

I'm baffled.

What caused the patient to decline so quickly? Was the patient in the process

of quickly declining when she came to you? If so, why wasn't the family already


Was the patient known to be actively dying when she came to you? It just

sounds to me like the patient was in pretty grave shape when she arrived and

the family should have been notified before the patient even got to your floor.

When I worked Med-Surge, there were times when I had patients who were

sent to the floor, pretty much just to die. Sometimes it would just be a matter

of hours.

Specializes in PICU, Sedation/Radiology, PACU.

In my opinion, if all you have is a piece of paper that says "DNR," then you treat the patient as you would any other until they require resuscitation. If you don't have any more details about what the patient wishes for their care, then you do everything except what it says not to do on the paper. If you do have more specifics, then you would follow those. I.E. comfort care measures only, no antibiotics, no vasopressors, no intubation, etc.

Not all patients with a DNR do not want treatment. Many are afraid of being placed on a ventilator and kept alive with machines, but they want to get treated while they are alive. For example, sometimes DNR's are rescinded prior to a surgical procedure. Clearly if the patient did not want treatment, they would not be consenting to surgery.

OP, it might be helpful to see if you have any policies about DNR ordered on your floor. It also might be helpful to you to bring this up with someone from the hospital ethics committee, if you're concerned with the way it was handled.

Specializes in Telemetry.

NurseCard, yes she was declining when I received her. (I did state my case that my floor was not appropriate, but that didn't change anything.)

The family dropped her off to me at 9P, beginning to accept she was in the dying process, but wanted to wait until they spoke to the docs and heard her new labs in the morning. They weren't fully there yet and so they left. I kept her in the same shape I had received her in, and she was hanging in there w/ acceptable pressure until poof, it was gone. I was consulting w/ my assistant manager the entire time, at least.

the family still wanted everything done until the next day at least. put me in a tough spot.

And thanks Ashley, that's how I understood it as well. I just wonder if there are people who think otherwise, because clearly the people responding felt that she should no longer be treated, despite the family's wishes. and i get it, that's almost an ethical dilemma in itself! keep bolusing someone, or let them go. legally- it's what is on paper which means keep bolusing. The whole thing is hard for me to grasp! and yes, I will absolutely be looking for a DNR policy.

You'd think I could have avoided all this by gently explaining to the family what was going on- but my manager and supervisor disagreed saying we can't give prognosis/ diagnose. what the heck. if nobody says it, how will they know! i am starting to think there may not have been a right answer because it's such a gray area.

Specializes in Med/Surge, Psych, LTC, Home Health.

Yes, you were very much put in a tough spot, and it sounds like you

handled it the best that you could, so kudos to you my dear. =)

Specializes in Oncology; medical specialty website.
Specializes in Emergent pre-hospital care as a medic.

If the patient or their healthcare POA has indicated the patient is to be a DNR then I'm not understanding why you would call the rapid response team who handles resuscitations to intervene. You treat the patients and you keep them comfortable but you do not take any heroic efforts to preserve the life...no bagging, no CPR, no defib, no intubation.

Specializes in Pedi.

In my experience, what you do in each situation is very individual. Working in pediatrics, when we had patients with DNR orders they were usually VERY specific. Once oncology patients became DNR, they were usually comfort measures only which meant that we weren't drawing labs, taking vitals or treating in any way other than with pain medication. I have also seen chronic patients with DNRs that had guidelines like: may intubate for respiratory arrest if parents are not present but no cardioversion under any circumstances, no intubation or cardioversion for an acute cardiac/respiratory arrest but may intubate on the short term if the problem is deemed to be reversible (acute hydrocephalus in that case). Some DNRs included guidelines such as no suctioning, no supplemental oxygen, no oral/nasal airway, no arrest medications, no venipuncture, etc. while others had guidelines such as "may treat with antibiotics if necessary."

Specializes in ICU.

Sounds like a rough situation. What is the function of your rapid response team? Are they a code team? If so, it would be inappropriate to call them. But if they respond to other calls such as chest pain, dropping pressures, etc then it was a good call. I would have called the MD again. He didn't give you any standing orders for what to do and didn't tell you what not to do with regards to the code status.

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