DNR ethics

DusktilDawn · Sep 13, 2005

Does this patient have an Advanced Directive or someone appointed POA in regards to her health?

If yes, the patient may have made it clear that she did not wish to have something like a feeding tube inserted.

Have you done any research in regards to palliative care? Hospice would be a good place to start and I'm sure they could provide you with a lot of info on the subject.

Tweety, BSN, RN · Sep 13, 2005

I always took it upon myself to deep suction patients who are DNR's and receiving comfort measures only...because after all isn't breathing easy a comfort measure?

Recently I read in our care plan, which is evidenced based (meaning research supports the idea), that we are not to do this, that is causes more distress to the patient who should be kept comfortable. I feel so guilty.

If someone isn't breathing comfortable, then it's time to up the pain meds or ativan, or other comfort measures besides suctioning.

You state she is terminally ill meaning whatever her condition, you aren't going to save her by feeding. Dying people don't eat. Don't force food, you are not starving her, it's part of her dying process.

Sounds like a great opportunity for you to learn the process of death and dying.

Best wishes.

elthia · Sep 13, 2005

The question is:

Is she DNR or is she DNR/palliative or comfort care only.

DNR does not mean "do not treat". DNR means that she is to be treated UNTIL her heart stops beating on its own, and then we withdraw care instead of calling a code.

Palliative/comfort care is different. The symptoms are treated from the standpoint that they have a terminal condition and aggressive treatment for the disease would be ineffective and cause more harm/discomfort to the patient. If the patient is terminal and is palliative care/hospice/comfort care then that should be documented in the chart somewhere by the attending. At my facility there has to be an order stating a pt is comfort care only.

You can do deep suctioning on a hospice patient, but use your nursing judgement. Mostly from your post, if the patient was in that much pain even with her morphine, I would say that pain management is the priority at the time. Then AFTER her pain was under control, discuss with her (if she is alert/oriented) if she would like suctioned. I have done this with comfort care patients that are alert and oriented, and many have told me if they needed/desired it or not.If the pt is comatose and death looks iminent in the next 24, I usually withdraw suctioning unless family requests it...I'd rather use scopalamine to "dry" up the secretions...less invasive and more comfortable.

Also, she might not be eating because she is dying...tube feeding would just prolong her pain...it's normal for terminal patients to not eat towards the end.

Tweety, BSN, RN · Sep 13, 2005

The question is:
Is she DNR or is she DNR/palliative or comfort care only.

Exactly, this needs to be clarified. The OP says "she may be on palliative because she's a hospice patient". It needs to be made certain.

Good point that DNR does not mean do not treat.

MaoKhan · Sep 13, 2005

wow thanks for the responses, I'm glad that there is documentation that it is advised not to suction because it will most likely cause more harm than good. That was a big issue today where us, the students, got pretty heated up and ended up being put under control by a higher ranking officer, lol. Not forcing the food makes sense too. What happens if the husband requests if the patient to be suctioned. Afterall when you step into the room, you can obviously tell the patient is laboriously breathing.

pricklypear · Sep 13, 2005

wow thanks for the responses, I'm glad that there is documentation that it is advised not to suction because it will most likely cause more harm than good. That was a big issue today where us, the students, got pretty heated up and ended up being put under control by a higher ranking officer, lol. Not forcing the food makes sense too. What happens if the husband requests if the patient to be suctioned. Afterall when you step into the room, you can obviously tell the patient is laboriously breathing.

Is her breathing actually labored, or just noisy? The issue can be a problem for the family - they perceive it as suffering. I usually tell people that I can try to decrease the noise by suctioning - and explain the procedure to them. I give them the reasons suctioning is not the best option. I've never had a family request suctioning after my spiel. Sometimes repositioning helps. You could try to just suction the back of her throat with a yankauer. It is less uncomfortable, and usually the source of the noise is back there, anyway.

I agree with the posters who mentioned that it sounds like this patient has inadequate pain/symptom control. A much bigger problem in my mind than the suctioning.

Antikigirl, ASN, RN · Sep 13, 2005

I have run into this as well, and thank goodness we have hospice on hand for my residents (I work Assisted Living) to provide comfort measures and orders to assist!

Most times deep suction is considered invasive, and against the comfort measure standards in my state, however..there is always that line of comfort if you can't breath because of mucous so far down. One of those catch 22's we all deal with.

Most times I have orders for oral suction only...and try other implementations to get those secretions up far enough to get! Using a pillow for coughing (most times we must place and help), humidified air (carefully!) or in their O2. Meds to help secretions loosen, position changes, purcussion therapy, the works. So far I am very lucky in getting those secretions up and where I can get them with very dilligent work, but sadly I am one nurse for 150 residents so it is really a juggling act, but I manage!

Hospice is the IDEAL! And I would advise everyone to use this vital service! I checked into three of the ones for my county and learned soooooooo much I couldn't believe it...so many myths countered, so many different and beautiful services uncovered...oh I absolutely love hospice!!!!! Learned a TON about pain management on end of life issues that I have no probelms with morphine or oxyfast or the like! Best to know the drugs then let myths and stereotypes cloud your judgement!!!!

But no matter what..it is our OWN percieved views that actually do make this situation work or not work. What we all feel individually on death and dying must be looked at with a fine toothed comb and realize that YOUR views are not necessarily the views of others when they are the ones suffering. Whether we think it is right or wrong...the patient should always be the one giving the orders. If she said DNR..she doesn't necessarly want invasive treatments...and to be allowed to die naturally with no advanced intervention. Putting a tube down the throat, any tube, is invasive so you have to weigh that carefully!

Good luck!

MaoKhan · Sep 13, 2005

well the patient was breathing at 26 resp a min! and was spiking a temp at the time as well. Her pulse ox was at 93% and it felt strange that no one checked twice about my finds. Maybe cuz i'm still relatively new to death and am only 20 years old :stone Wow i never knew states had their own laws on comfort care! and now that I think about it, I'm finding it more and more strange that the patient appeared to be as distressed as I had found her with morphine! I think I'll bring that up tomorrow if I get a chance. I guess the problem with using our own judgements is because us students are still relatively low in rank and we're used to taking orders, not making the judgements. From the information we gathered, the patient being DNR, we felt that didn't imply allowing the patient to rot herself away by refusing all treatment, food, and water. Anyone of you know good sources to read up on this information. I would very much like to give a presentation on it. Again I greatly appreciate the help!

MaoKhan · Sep 13, 2005

Hmm...thought up of unique hypothetical cases such as what if the patient was in this state and wanted to sleep face down in her pillow. Whatever we did she would roll back over and didn't want our intervention. Do we have the obligation to allow her to do something like that? Or would that constitute negligence? I know it's far fetched but it feels like leaving something you know that may eventually occlude the patient's airway may be straight up negligence. yes even if she is dying.

Antikigirl, ASN, RN · Sep 13, 2005

Actually, Oregon Health and Sciences University is top NOTCH in their medical ethics and POLST, best in the US!

Check out their website at http://www.ohsu.edu/ethics/polst/ and take the time to compare with your states laws (usually I find the top of the healthcare universities..they normally have the largest group of medical ethics commitees!).

I know more than most RN's in my state because I help OHSU with info on the geriatric population, and I also work with EMS closely! I find these choices on life sustaining treatment to be the largest gap in communication for all concerned!

It would be an awesome informative piece for your education and school! Heck..I chose it, aced the debate and report for senior RN school...and many nurses come to me or my hubby for the latest in POLST information! I am very proud to be a part of that!

Read the actual POLST form...it has changed..it is so cool! It defines the different options so much better than one a year ago! I am sure it would be of great benifit and info for you...even if your state doesn't adhere to it (or since you are millitary...your millitary organization...hubby and I were Navy).

If you have any questions or want to hear of some stories where this POLST went right or wrong for your research...give me a private message! I have many stories...most thank GOD turned out a okay despite the communication breakdowns! I also have some heart warming stories as well :)

Antikigirl, ASN, RN · Sep 13, 2005

Oh heck..example! Had a lady with severe asthma fall down and wasn't breathing. I chose to start CPR efforts because at the time no DNR's were in patients rooms (they are now!). THe caregiver ran to get the chart and found she was a DNR! Now, before you all go "oops!"....she had a heartbeat! I can only honor a DNR if they are pulseless and apenic...so I was in the clear!!!!!!

Got her back with mouth to mouth and sternal rubs really...which amazed me...and didn't have to go to invasive (since she was a serious asthmatic I was dumbfounded!). Paramedics came and took her to the ER, she stayed three days..and lived with no complications!!!!!! YEAH!!!!!

THen we found out...her family, who is her POA medically and financialy had NO IDEA she had a DNR, and in fact they are a subsect of the Quakers and do not believe in DNR! Someone dropped the ball...Polst filled out wrong....so I was in the right all along and the POLST was changed! WHEWWWWWWWWW!!!!!!

They still call me their hero, and send me home made pies, flowers from their garden, and other county gifts that are so great...even though I told them not too..LOL! OH I love those folks, and so glad I helped..if it wasn't me being the nurse that day...well...she would have died, I have no doubt because despite my teaching..the other nurses feel DNR means DO NOTHING...grrrrrrrrrrrrrrrrr!!!!!!!!!!