DNR- Do Not Treat?

withasmilelpn · Jun 18, 2012

This is very difficult. DNRs really only indicate what we should do should a patient go into resp arrest or cardiac arrest. Up until that moment / anything goes. The parents did not want their child to die - they wanted everything done to keep an arrest from happening. I'm not sure what your rapid response team is responsible for - if they only are present to resuscitate someone then I can't blame their attitude - but usually rapid response teams are on hand to help keep someone from coding in my experience. If that is the case, then you were entirely correct in calling them. In fact - it never matters what we healthcare workers think - whether we think it's appropriate, inevitable, whatever - we are obligated to provide care. Also - I always tell families what I think in the gentlest way possible that things don't look very good, I want to prepare them, in my experience...etc, etc, - it's possible to level with people in such a way without ever 'diagnosing' someone. You can also ask them what they are thinking - but even bluntly telling someone that they love is going to die (which I would never do) - does not guarantee acceptance. You have a legal obligation to care for your patient according to medical standards of care and if you chose to 'slow code' or deny or delay treatment - the family would be in their rights to sue.

Not an easy thing at all.

I think you handled it as best as you could.

Your coworkers require some education I think.

jadelpn, LPN, EMT-B · Jun 18, 2012

We need an order from the MD that says DNR/DNI. Not just a piece of paper that says so. If the patient is unresponsive, then it would be the HCP who would then have to decide to change that. Sounds to me that if the HCP wanted the patient to be "kept alive until morning" (assuming it was the HCP who stated that, and not just random family)then I would have explained to the HCP the grave nature of the patient, and asked the MD to come in to talk about DNR/DNI status, as the patient was unstable, and the HCP was wanting the patient alive until morning. IF you did not have a DNR order, and if the HCP said "keep her alive", then a full RRT would have had to been started, up to a code, as you have to have a DNR order (in my state anyways), and the HCP can decide at any time (or the patient) that they want to be a full code. The rapid response team and the code team are two seperate teams. If RR doesn't work to SUBSTAIN life, and patient codes, THEN it becomes an issue of compressions, intubations, and the like, to try and "bring someone back" from life that has ceased, not interventions like cardizem or nebs to a person who is alive (no matter how precariously). I like to gauge exactly where the family is at prior to them leaving with a "if something happens, call us". They need to understand that the conditon is poor, and that they need to speak with the MD regarding exactly what advanced life support they would like for their mother/father/sister etc. and that with patient being so unstable, the outcome may not be satisfactory. Always go with your order, and let MD have discussion to change that order if needed on unresponsive patient to the HCP wishes. Now for the public service announcement:

It is so important that everyone, no matter if ill or not, should be careful who their HCP is, and that they understand what your wishes are. As your voice when you don't have one, they can decide your fate for you. They have the final say when you can't speak for yourself....

xtine618 · Jun 18, 2012

And I wanted to add, I've seen a couple comments about a "slow code". If your patient truly is a DNR, then there should not be a code at all. Slow or otherwise.

JEN077 · Jun 18, 2012

some of the personel around the place i work also say things like "why are we doing this? the patient is a dnr?" . i am constantly saying that does not mean we aren't here to treat them and give them antibiotics and labs and such. unless they are comfort care only. there is either a huge misperception or maybe they are a little burned out. after i say this they usually shake their heads and say " you are right". i also heard some one say something about a patient being a slow code the other day and asked what that meant. i had never heard of such. sounds a little half a$$ed to me. i'm learning every day and just hope that maybe i can help change the way some people percieve things like this. i also have a huge respect for hospice. i also think the op did what she should have in the end you do the best for your patient not your co-workers.

Esme12, ASN, BSN, RN · Jun 18, 2012

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.

This is a very polarizing area. There are some that have very strong feelings that a DNR in such a rapid decline should be left to die in peace.

DNR means Do Not Resuscitate. But the patient deserves to have treatable issues resolved. It really is up to the family what they wish. I have seen DNR's on pressors supporting them. Tube feedings feeding them. Antibiotics when the have an infection. DNR means that when the code you do not code them. Some facilities have DNR's the specify what treatments are and are not allowed.....families can specify what they wish to be done.

Many states have instituted what is all "comfort care" which allows that only comfort measures be taken and is recognized by EMT personnel. Know your facilities policy. We can't diagnose but as you gain more experience you will be better at dealing with families.

I always tell families that their loved one is really not doing well and is critical....that I do not have a crystal ball to give them a definitive answer about recovery/chances/time of death but that their loved one is very ill and has lived a long life or fought very hard and they are tired......I reassure them that their loved one will be cared for with love and if something happens they have to promise to drive very careful back to the hospital.

A rapid response is for help....not a code. I would be sure the team knows this and that the family is treating aggressively and you need help. If they complain...ignore them. You are doing your best. It doesn't get easier but you will get better at it.

Well done! :hug:

NO50FRANNY · Jun 18, 2012

Under the circumstances I don't think I would have done anything differently. You said that the family wanted everything done for her at least until the next day as they were still coming to terms with her prognosis, so she needed all the care that you provided. DNR means just that, no heroic measures but there are always grey areas. Specific end-points or wishes should be discussed and documented as early as possible and in a perfect world this would happen for all our dying patients. Unfortunately, physicians often leave it too late to discuss end of life care and nurses inevitably are directly responsible for facilitating this when the patient deteriorates. The situation was critical and you acted with your patient's and her family's wishes / best interests in mind. There will always be debate about what is considered "resuscitation" or heroic measures. Our not for resuscitation paperwork is very specific, with check boxes, eg.-not for: intubation /CPR / inotropes, or provide adrenaline but not CPR or provide fluids and anti-biotics but not enteral feeding and so on, very specific. Do not resuscitate does not mean do not treat until someone makes a decision to palliate the patient and initiates comfort measures. Withdrawing treatment was a decision that the family obviously had not made yet so you were obliged to do everything you could. I do understand the rapid response teams' attitude to an extent, we are doing all these often unpleasant, invasive things when all we can think is that the kindest thing we can do is let them go (I often feel this way). But, we have to do what we have to do. You did great under the circumstances :)

imintrouble, BSN, RN · Jun 18, 2012

The fact that this critically ill pt was admitted to a med/surg floor, instead of SCU, essentially said it all.

Penelope_Pitstop, BSN, RN · Jun 18, 2012

The fact that this critically ill pt was admitted to a med/surg floor, instead of SCU, essentially said it all.

I respectfully disagree.

Every facility is different in regards to how a patient's admitting acuity is determined. The vast majority of transfers to higher levels of care in my hospital are made within the first 24 hours of admission, and a lot of those cases don't experience sudden declines...they arrived too sick for the floor in the first place but due to extenuating circumstances (bed availability, attending physician not willing to change patient status, rapid response nurse not convinced patient is inappropriate for floor) it takes some time to get things moving along.

But then again, that is my hospital.

To the OP: it sounds like you were to do everything in your power to prevent death, whereas in the event of respiratory or cardiac arrest, you were to do nothing. I think you carried out the orders appropriately. That's a scary situation but you did well.

Good Morning, Gil · Jun 18, 2012

This is the kind of thing I see with fair regularity in our ICU. You did the right thing. DNR does not mean "Do not treat" regardless of the hard time people were giving you; I don't really understand why people have a hard time of grasping this (not you, but the people that were giving you a hard time; it's pretty cut and dry). It means do not resuscitate, so you do everything for the patient you would normally do, except CPR, ACLS drugs, and intubation (or whatever your hospital policy dictates). They were giving you a hard time because they believed the patient should die, but their beliefs don't matter. DNR means DNR, and it's the next of kin's decision, even if they make what you believe to be the wrong choice.

So, fluid boluses are appropriate even though you know this poor person is terminal and ready to die.

What you could have done if you didn't do it: you advocate for your patient, and tell the doc the first time over the phone that this patient is a DNR, and terminal. You need to come speak with the family regarding prognosis and making this patient comfort care only. So, he/she facilitates that discussion with the family (since it is beyond our scope to initiate that discussion even if it is obvious what the prognosis is), and the next of kin makes the decision on how they want to proceed, continue with treatment or make the patient comfort care.

DYLANB · Jun 18, 2012

I understand your desire to keep the patient alive until family arrived. I can see your dilema but, there does come a time when treating a rapidly declining DNR is like beating a dead horse, no offense or pun intended. A patient that sick requiring drips and bolus' should probaby have been in an ICU or CVICU to begin with regardless of code status. If that had been me I would have sought a Withdrawl of Care from the family. Assuming the family agreed, I would have then called the MD and notified him of the families decison to withdraw care and asked him to make the patient Comfort Measures only which in most case means death is immanent. Generous amounts (hopefully) of morphine would have been prescribed and the pt would have been allowed to pass in his/her own time comfortably. if the family did not agree to withdraw care despite having explained the pts situation and the fact that death was not a matter of if but when, then I would have called the MD and asked for a set of standing orders related to blood pressure maintenance and pain control. I don't know that this answers your question entirely but hopefully it helps.

Been there,done that, ASN, RN · Jun 18, 2012

I am sorry you did not get the support you needed.

From administration.. to the doctors.. to the rapid response team. In my facility. I would expect the RRT to assist me..as this was not a code. Look at their job description .. that will tell you what you need to know about THAT issue.

The treatment of a DNR designated patient has been an ongoing issue in my 30 years of nursing.

We would think (and hope) that , this extremely important issue would have been clarified by now!

Legally, you needed to treat the low blood pressure and the patients decline . Morally? who knows.. ethically? who knows?

Consider taking this to your hospitals ethics committee. Your management is wishy-washy at best.

You did the best you could.. given the mess you were handled.

Altra, BSN, RN · Jun 18, 2012

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.

This.