DNR- Do Not Treat?

grammasue7 · Jun 21, 2012

do not resuscitate means just what it says...it doesn't mean do not treat. in cases of terminal illness many physicians will order comfort measures only in addition to the dnr (after discussing this with the family of course). since this isn't mentioned i assume this wasn't the case and i would have done as you did and continued to get orders and treat symptoms as they arose. you did nothing wrong given the orders and situation you describe. we in the health care field must advocate for our patient's and their families. the fact that you put the needs of the patient and family first, regardless of how co-workers treated you, tells me you are the nurse i would want caring for my loved one when the time comes. kudos to you...and i would have to question if some of the health care workers you encountered are in the correct job or maybe should be considering retirement.

RNMeg · Jun 21, 2012

I was in a similar situation. The patient had a No Code order, but was clearly septic (tachy, hypotensive, diaphoretic, source of infection, lactic and white count through the roof, etc). She was declining steadily on my shift, and I was torn. Do I call the doctor and initiate severe sepsis protocol (which would likely end with her intubated), or do I allow her to continue declining? I went with my gut, called the doctor, got some orders that would stave off some of the worse symptoms without doing SSP, and as I hung up with the doctor she died. I was glad I at least called and got orders, even though in the end it was futile. That was an awkward call to the doc 10 minutes later, though.

rita359 · Jun 21, 2012

I think you did the right thing. After all , you called a rapid response team not a code team. You may get some of the same people for both but the functions of each are different. Sometime a rapid response evolves into a code. Many times they do not. The way I see it is you got to a point in this patients care where you needed to see if there was some other option and you tried to get opinions from more highly skilled people. Unfortunately, they failed you. Sounds like they may need some more education.

It might be well to address their responses with your nurse manager. Those kinds of responses can keep nurses from calling rapid response teams which, in the end, is a bad thing.

rnlately · Jun 22, 2014

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.)

This sound identical to what happened to me the other day. I call the rapid response, unit nurses came and attempted to make us look like idiots. I don't feel bad though. I still maintain that I/we did the right thing. Some others obviously need to know that Dnr doesn't mean do not treat.

calivianya, BSN, RN · Jun 22, 2014

A lot of the nurses at my facility act like this and it makes me so mad I could throw them through the window! DNR/DNI only applies when the heart/breathing stops if the patient/family still wants everything else to be done. We have a form with three options - DNI (only no intubation, everything else allowed), DNR (no compressions and no intubation, with boxes to check below for what interventions the patient DOES want), and comfort care only. Comfort care only is the ONLY selection in which we would let someone like the pt. you described just go ahead and die. The DNR selection can include labs, imaging, dialysis, pressors/epi/code drugs, TPN, tube feedings, antibiotics... anything you can imagine besides doing compressions and intubating. There is NO REASON to think someone with a DNR doesn't want boluses and antibiotics. There is also no reason to assume a DNR patient is DNR because they want to die. It is just so frustrating to watch other nurses go, "Oh, she's just a DNR" as if that nullifies their responsibility to do anything for the patient at all.

allnurses Guide · Jun 22, 2014

A nurse friend's husband is in his eighties with several chronic illnesses and early stage cancer. His physician and hospital know he is to be DNR if he codes.

Recently he developed SOB and a fever. His wife took him to the ER where they laughed and told her, "He is a no code". He was alert and talking.

She had them call the nurse administrator, shift supervisor, and medical director. She said, "My husband in DNR, not "Do not treat." Diagnose and treat him!

He was diagnosed with pneumonia and give antibiotics, O2, and breathing treatments.

Three days later he was discharged They went out to dinner Father's day. He had a great time with his children and grand children. He joked around in a clever way.

I hope those ER staff, including the Er Doc understand better now. I hope your RRT people learn. As a CCU nurse I prayed for all of you. They need an inservice. RRT is not the code team.

Here.I.Stand, BSN, RN · Jun 22, 2014

I see this is an older thread, but I think the provider should have gotten on the phone with the family (assuming the pt couldn't tell you what he wanted) and advised them that in the absence of a reversible cause (such as septic shock which can be treated w/ IV antibiotics and fluids) he is declining quickly, his BP is down to 60s/40s and the pt is likely headed for a transfer to the ICU and may need medical support to maintain his VS. What would they like done?

There's a range of treatment, from oral antibiotics to everything-but-the-vent-and-defibrillator. The "heroic measures" are not always in the patient's best interest.

SeattleJess · Jun 22, 2014

Treatment cannot be withheld in Washington unless there is a written directive from the patient. In Washington state, DNR means "CPR should not be attempted in the event of heart failure." It doesn't mean do not treat.

Since 1992, the Washington State Natural Death Act allows a patient to execute advance care directives (POLSTs, Physician Orders for Life-Sustaining Treatment) that cover a broad range of end-of-life decisions, including resuscitation. Without a POLST instructing you of the patient's requirement that you not provide the specific treatments you gave, you cannot withhold treatment in Washington without subjecting yourself to liability. In fact, there was an issue recently about a "loophole" in the law that might have resulted in liability for ALFs and home caregivers who followed a POLST, so narrowly are these laws construed.

I have no experience as healthcare personnel; my experience is on the legal side. What happens in actual situations in healthcare in gray areas or under the radar, I do not know. I do know your intentions here conform to the law in Washington.

This is a bit of tangent, but... I am nearing the end of Five Days at Memorial by Sheri Fink that tells about the situation of healthcare personnel at Memorial Hospital during Katrina. That was a situation where doctors and nurses, faced with extremely difficult circumstances, decided that DNR meant "do not treat" and in fact, euthanize. The situation amplified the issues that are always present in healthcare, I think: the limits on healthcare resources and the difficulty of making decisions about who gets them and how and the difficulty of making end of life decisions in those gray areas. Style is somewhat overlong and plodding but still a valuable read.

Nursing doesn't get a pass from our thorniest social and spiritual issues.

MunoRN, RN · Jun 22, 2014

Treatment cannot be withheld in Washington unless there is a written directive from the patient. In Washington state, DNR means "CPR should not be attempted in the event of heart failure." It doesn't mean do not treat.
Since 1992, the Washington State Natural Death Act allows a patient to execute advance care directives (POLSTs, Physician Orders for Life-Sustaining Treatment) that cover a broad range of end-of-life decisions, including resuscitation. Without a POLST instructing you of the patient's requirement that you not provide the specific treatments you gave, you cannot withhold treatment in Washington without subjecting yourself to liability. In fact, there was an issue recently about a "loophole" in the law that might have resulted in liability for ALFs and home caregivers who followed a POLST, so narrowly are these laws construed.
I have no experience as healthcare personnel; my experience is on the legal side. What happens in actual situations in healthcare in gray areas or under the radar, I do not know. I do know your intentions here conform to the law in Washington.
This is a bit of tangent, but... I am nearing the end of Five Days at Memorial by Sheri Fink that tells about the situation of healthcare personnel at Memorial Hospital during Katrina. That was a situation where doctors and nurses, faced with extremely difficult circumstances, decided that DNR meant "do not treat" and in fact, euthanize. The situation amplified the issues that are always present in healthcare, I think: the limits on healthcare resources and the difficulty of making decisions about who gets them and how and the difficulty of making end of life decisions in those gray areas. Style is somewhat overlong and plodding but still a valuable read.
Nursing doesn't get a pass from our thorniest social and spiritual issues.

Maybe I read your post wrong, but Washington's natural death act states that measure to provide comfort cannot be withheld, not life prolonging treatment. Medical futility can still be declared on patients in Washington state, all the law states is that non-physicans/LIP's cannot declare medical futility.

brogemm · Oct 15, 2014

Sounds to me like you did the appropriate thing. It's already been commented, but I will echo that DNR does not mean "do not treat". DNR only comes into play if they go into cardiac arrest. Until that happens, we continue to treat to the fullest (unless, of course they have other stipulations in their DNR such as no intubation, no antibiotics, etc., in which case we treat within those confines). If your patient had CMO (comfort measures only) orders, that would be an entirely different story.

But some of the comment about rapid response teams made me realize that "code teams" may have different roles depending on what hospital/region you are in. In my hospital system, code teams respond to both Condition C's (critical) and Condition A's (arrest). Condition C is reserved for patients who are deteriorating but are still alive. But I know there are hospitals that treat this kind of situation differently (i.e. call the doctor, manage it with the unit's own nurses) and the code team responds only if the patient arrests.

In any case, your patient was deteriorating (but still alive!), so the DNR order did not apply yet. It sounds like you tried to go through the proper channels and finally called the code team when you did not get the appropriate response for your patient. Good for you for advocating for your patient.

Loo17 · Oct 15, 2014

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.

The patient did not need cpr, bagging, or intubation at that point. Where I work on the inpatient units rapid responses are called for any rapid decline in patient condition requiring immediate assistance regardless if they are a DNR. I think the OP did the right thing. Unfortunately in my experience many healthcare workers think DNR means do not treat. It does not. Unless there are specific requests made to do nothing, you do everything except CPR.