DNR form not filled out completely

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Hey guys I have a really important question to ask. I just graduated this may and currently working in a nursing home. I have one resident whom just coded today.

Upon arriving on shift, my unit manager told me that the patient is still full-code and not DNR. The DNR out-of-hospital order form is still haven't been filled out by the doctor, hospice, and the nephew (the responsible party of the resident).

While doing rounds and preparing to put on wound care dressing on this resident I saw that she was having trouble breathing and using her accessory muscles. I immediately took her vitals and Sp02. The Vitals were BP= 89/53 Pulse= 116 Respirations= 27 and Temp 97.4. Her Sp02 was 85% and steadily declining. I called respiratory right away to give her some oxygen which her sP02 increased to 79%.

I had to call 911 to come pick her up.

The question is I saw in her chart that the doctor did put down DNR and sign it in one of those receipt attachment form. However, it wasn't an official out-of-hospital DNR order form. I called the director of nursing and she told me the patient is DNR. I rush to the patient's chart and pull out that particular DNR form to show to the EMS people. They told me that form isn't valid because its one of those tear off form. It has to be an official out-of-hospital DNR form for her to be DNR. They took her to the hospital.

I'm really worried because 1) there was a DNR order from the doctor. 2) The doctor nor the nephew has officially sign on the out-of-hospital DNR order form.

I'm stuck between which one to follow. I'm really stress out right now. I had to stay back 4 hours to do paperwork and check if everything was correct. I did saw in the chart that her last advance directive flowsheet was done on 10/19/11 which was 2 years ago. That one still listed her as full-code and not DNR.

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DNR does not stand for Do not treat. It sounds like she did not code at your facility so it is out of your hands. I'm my state, if a person codes in the ambulance they do CPR regardless of code status. I'd say as long as you sent the necessary paperwork along then it is the hospital that would be up to them to decide how to proceed.

It is always good to clarify code status if possible. We had a lady that started a general decline that carried into a weekend and was a full code. Her daughter decided that she wanted to make her a DNR. We called the on call and expressed her wishes. He was able to talk to the POA and give us a TVO and that was considered sufficient at our facility.

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Specializes in Pediatrics, Emergency, Trauma.
DNR does not stand for Do not treat. It sounds like she did not code at your facility so it is out of your hands.

THIS. :yes:

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

A DNR is not a do not treat. You administered oxygen.....perfectly acceptable. You called 911...again Ok. Just because someone is a DNT doesn't mean they shouldn't get lasix to help them breathe or antibiotics to help a urinary tract infection.

A DNR means you won't do CPR or perform life saving measures...like intubation, defibrillation, and pressors.

Without a signed DNR there is no DNR.

CaringGerinurse525 is incorrect about EMS having to have to do CPR. I believe that all states have out of hospital DNR status which when signed allows EMS to withhold resuscitative efforts.

In my state it is called Comfort Care.... MOLST and Comfort Care DNR Verification

In PA it is called a out of hospital DNR order.....DNR Order - Pennsylvania

TX out of hospital do not resuscitate order...http://codes.lp.findlaw.com/txstatutes/HS/2/H/166/C

Do Not Resuscitate Orders and Comfort Care Ohio

Are a few examples....But these need to be filled out and signed for them to be valid.

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Specializes in Complex pedi to LTC/SA & now a manager.

The big issue in calling 911 would be if there was a DNH (do not hospitalize order ) My father was made a DNR, DNI, DNH. & on hospice. One nurse panicked and sent him out for possible UTI then called us & hospice. It was a big unnecessary mess especially since hospice was awesome and had wonderful care plans & med orders in place.

If she had fallen with a possible hip fracture & DNR you would still call 911 for an ER evaluation and at minimum pain management if surgery wasn't an option.

EMS in some states not initiate CPR after consult with ED medical control if there isn't legislation permitting EMS to accept facility specific DNR forms at face value.

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A DNR is not a do not treat. You administered oxygen.....perfectly acceptable. You called 911...again Ok. Just because someone is a DNT doesn't mean they shouldn't get lasix to help them breathe or antibiotics to help a urinary tract infection. A DNR means you won't do CPR or perform life saving measures...like intubation defibrillation, and pressors. Without a signed DNR there is no DNR. CaringGerinurse525 is incorrect about EMS having to have to do CPR. I believe that all states have out of hospital DNR status which when signed allows EMS to withhold resuscitative efforts. In my state it is called Comfort Care.... MOLST and Comfort Care DNR Verification In PA it is called a out of hospital DNR order.....DNR Order - Pennsylvania TX out of hospital do not resuscitate order...http://codes.lp.findlaw.com/txstatutes/HS/2/H/166/C Do Not Resuscitate Orders and Comfort Care Ohio Are a few examples....But these need to be filled out and signed for them to be valid.

I may be wrong, Esme but I know at my facility we are told that out DNR forms are not upheld in the ambulance. We have a gentleman on hospice right now and his family had to request a specific form to sign so that there was no chance they would resuscitate him. This was news to me because I assumed if the hospital would honor the DNR then so would EMS. I am a fairly new nurse so when the situation arose I spoke with the RN's, DON and social worker. They all told me it was standard protocol that the Ems are held to a different standard.

I will have to investigate this further. Thanks for the heads up.

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Specializes in Complex pedi to LTC/SA & now a manager.
I may be wrong Esme but I know at my facility we are told that out DNR forms are not upheld in the ambulance. We have a gentleman on hospice right now and his family had to request a specific form to sign so that there was no chance they would resuscitate him. This was news to me because I assumed if the hospital would honor the DNR then so would EMS. I am a fairly new nurse so when the situation arose I spoke with the RN's, DON and social worker. They all told me it was standard protocol that the Ems are held to a different standard. I will have to investigate this further. Thanks for the heads up.[/quote']

For what reason would you be calling EMS anyway?

I know many hospice agencies encourage patients/families to sign DNH (do not hospitalize) orders depending on diagnosis/prognosis. Check also with the hospice case manager they often have suggestions for interventions and when it is necessary to send out for further eval.

In my father's case, at the end sending him to evaluate/treat pneumonia or a UTI would be of little benefit and likely cause more harm (such as more c. diff. , MRSE, VRE, or other MDR superinfection). Hospice had comfort orders for Tylenol, morphine, atropine and other palliative measures. So he was made a DNR/DNI/DNH.

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For what reason would you be calling EMS anyway? I know many hospice agencies encourage patients/families to sign DNH (do not hospitalize) orders depending on diagnosis/prognosis. Check also with the hospice case manager they often have suggestions for interventions and when it is necessary to send out for further eval. In my father's case at the end sending him to evaluate/treat pneumonia or a UTI would be of little benefit and likely cause more harm (such as more c. diff. , MRSE, VRE, or other MDR superinfection). Hospice had comfort orders for Tylenol, morphine, atropine and other palliative measures. So he was made a DNR/DNI/DNH.[/quote']

Our DNR's are not always do not hospitalize. I was just using the hospice patient as an example. We would send a hospice patient out if they fell and we suspected a fracture. This is the situation the family was concerned about because he has a hx of falls.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I may be wrong, Esme but I know at my facility we are told that out DNR forms are not upheld in the ambulance. We have a gentleman on hospice right now and his family had to request a specific form to sign so that there was no chance they would resuscitate him. This was news to me because I assumed if the hospital would honor the DNR then so would EMS. I am a fairly new nurse so when the situation arose I spoke with the RN's, DON and social worker. They all told me it was standard protocol that the Ems are held to a different standard.

I will have to investigate this further. Thanks for the heads up.

That is correct......DNR's are not held up by EMS.....a different form needs to be filled out.

For my state....and this is similar to most if not all states. A DNR is a hospital/facility binding document. In order for EMS to honor the DNR the patient/family and physician need to fill out a separate form indicating that the patient has a separate status for the EMS to follow. Right now my state is transitioning to a more specific form but in general....

The Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) and Comfort Care/Do Not Resuscitate Order Verification (CC/DNR) forms are statewide standardized forms issued by the Massachusetts Department of Public Health, which patients and their health care providers can use to document the results of discussions they have had regarding appropriate life-sustaining treatment. These are the only documents that ambulance services and their EMTs and paramedics can immediately recognize and honor as an actionable order (in the case of MOLST) or verification of such an order (CC/DNR form) regarding the use or limitation of use of life-sustaining treatments for their patients. Massachusetts is currently transitioning to use of the MOLST form, but EMS personnel will continue to encounter patients with CC/DNR forms. At this time, patients may have either form, and as long as the form is current and valid, EMS personnel may honor either document.
MOLST and Comfort Care DNR Verification

If you don't mind me asking.....which state are you from? Many nurses NOT involved in the EMS sstem of emergency medicine are unfamiliar about these regulations. The MD's SHOULD know...but we know how that goes.......

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I live in PA. I read the link you posted pertaining to PA. I work in LTC so I do not have as much experience with EMS as some nurses do. It is interesting to learn that a separate form is required. I will be sure to pass this information on to the other nurses I work with that may also not be aware. Thank you!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

That was a lucky....I posted where I have worked before...LOL...you are very welcome

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Specializes in Complex pedi to LTC/SA & now a manager.
Our DNR's are not always do not hospitalize. I was just using the hospice patient as an example. We would send a hospice patient out if they fell and we suspected a fracture. This is the situation the family was concerned about because he has a hx of falls.

I just meant in general. If a hospice patient is near the end and there isn't anything that would be gained by an ER eval or admission hospice recommends a DNH.

My dad wasn't a DNH until the last month or so. In the beginning he was a DNR, then DNR/DNI, finally DNH. In the end if my father fell it would be a big issue as he was non ambulatory and someone either dropped him or didn't follow safety measures.

Your example would be demonstrating DNR does not equal " do not treat" and staff/family education needed to ensure proper paperwork on file if EMS needed. Hopefully hospice nurse or social worker is proactive and ensuring proper paperwork in place before EMS or hospitalization needed.

In my father's case I was former EMS plus his hospice nurse was AWESOME and ensured all paperwork was in place for DNR in facility, EMS, and if transferred to hospital. The hospice nurse also ensured his facility staff knew the correct paperwork & parameters to send dad out if appropriate. (Even though one sent him out for a UTI without checking with even family first ) Unfortunately it seems this is not the norm.

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