DNR help?!?!!

tokebi · Sep 11, 2013

Always remember that "Do Not Resuscitate" does not equal "Do Not Treat."

When I worked in LTC, we sent out residents regardless of DNR status unless there was an MD order specifically saying not to call 911. For example, suppose a DNR resident developed sepsis requiring treatment beyond what nursing home could provide. The resident will go to a hospital, get antibiotics and monitoring, and then come back in better health. If the resident deteriorates while in the hospital though, a code won't be called as the patient is DNR.

If you encounter a resident who is DNR and actively dying -- which you definitely will -- there are plenty things you can do to "help." Patients are put on DNR status when they decide to focus on quality of life rather than prolongation of life due to their old age or terminal illness. Therefore, what we do for them as nurses will be mainly comfort measures, not heroics.

Some examples of what you can do:

Medicate for pain.

Provide oxygen if they're short of breath.

Keep them clean.

Control secretions.

Comfort them if they're scared/distressed.

Keep them company if no one's there (who wants to die alone?)

laderalis · Sep 11, 2013

DNR means, in my facility which is a rehab/LTC, I'm not going to hook them up to the AED, should they be found not breathing with no pulse.

It has NOTHING to do with treatment before that point. I would do the same for them as I would for a patient that is full code. Hospice, however is another ball game. DNR does not mean hospice.

DNR means do not resuscitate, NOT do not treat.

nurseprnRN, BSN, RN · Sep 11, 2013

It makes me nervous to think about the first time someone is actively dying and me not being able to resuscitate them or help them.
I understand why DNR orders are placed and i do not disagree with them. However, I am not a very good "bystander", I like to jump in and help. It's hard to imagine any other way. Any advice/insight/stories would be helpful.

Help comes in many forms. When someone is DNR and is actively dying, resuscitation is not help. "Don't just do something, stand there" applies here.

You have nothing to fear from experiencing your first death, especially if it is expected and welcome. Do not fear it. Be present for the person who is passing before your eyes; it is a gift to you as much as to her. There are cultures that believe the moment of a death bestows wisdom and peace upon the witness; take that to heart.

chrisrn24 · Sep 12, 2013

DNR means, in my facility which is a rehab/LTC, I'm not going to hook them up to the AED, should they be found not breathing with no pulse.
It has NOTHING to do with treatment before that point. I would do the same for them as I would for a patient that is full code. Hospice, however is another ball game. DNR does not mean hospice.
DNR means do not resuscitate, NOT do not treat.

Thank you!

OP if your fellow nurses ignored this man you would feel much, much worse than seeing a patient who is ready to die to.

Death is not that bad to watch - at least not in elderly people who've lived a long happy life. I have yet to see a tragic death so I can't speak for that.

canned_bread · Sep 18, 2013

I have only handled a few of these experiences, and it's hard on the heart sometimes. It sounds liek you have a lovely heart.

I have never had a patient with a DNR ask me to save them at the last moment, that would be difficult! I don't even know what to do then - do you get someone to witness it and then proceed in saving?

With final moments, I make them comfortable. If they have pain meds charted, I give them regularly. If they don't, I get them charted. I place oxygen on them in as non-invasive way as possible. And always, if possible, I sit by them and chat to them, or massage their hands with sorbelene if they are alone. No one should die alone. I also, if it will make the patient more comfortable and is not required, remove as much as possible. I also believe that even if a patient is unconscious, they can still hear, so I chat to them as much as possible as I do their care.

Nursing when a patient is dying is at the heart of nursing I think, it's where we can truly show our love for what we do.

Brandi,RN · Jul 12, 2016

Definately what others have said. DNR does NOT mean do not treat, not at all. We send DNRs out via ambulance and all. For level 3s we confer with family because generally they don't want them sent out. But you don't let someone lay there is respiratory distress or having an MI because they are a DNR.

jadelpn, LPN, EMT-B · Jul 12, 2016

There are some facilities who have not only DNR's in place, but do not hospitalize in place as well. Hospitalize for comfort only forms.

There are more specific forms than a DNR which spells out more clearly the wishes of the resident.

As others have noted, DNR does not mean "do not treat" but there are more specific forms to be clearer on what the wants of the resident are in regards to hospitalization and the like.

akulahawkRN, ADN, RN, EMT-P · Jul 12, 2016

As others have noted, DNR does not mean "do not treat" but there are more specific forms to be clearer on what the wants of the resident are in regards to hospitalization and the like.

From my EMTP side, the DNR is very specific about what it allows and doesn't allow. In the instant case the DNR would allow me to provide oxygen and IV fluids but NO intubation/PPV and no cardiotonic drugs (no pressors), among other very specific restrictions. It also allows transport of the patient to a higher level of care in the event that a reversible cause of a problem is found... assuming that the patient is alive to begin with.

Here in California, we have a POLST form that can act as a DNR form but it's also much more explicit about what the patient wants in specific circumstances.

In any event, learn what laws exist regarding this in your area, learn what your facility/agency policies are, and also become at least familiar with the policy that your EMS providers have in regards to DNR/POLST issues. In some instances, it is possible that EMS may decline to transport your dying patient (basically) because it serves no benefit for the patient.

nutella, MSN, RN · Jul 12, 2016

Others have already mentioned the difference between DNR and "do not treat" / comfort measures only.

I would like to encourage you to think about your relationship with death and dying and explore your view on that.

Part of the discomfort with that topic comes from the notion that people regard death as "abnormal" instead of a normal process at the end of life (whenever that may be). In the US death is often viewed as "optional" and a "failure" , when in fact it is just normal that when we get older or sicker, we also approach the end of life.

Atul Gawande’s 5 Questions to Ask at Life’s End - Next Avenue

In any way, the way I explain it to people is that when we are young and/or more healthy, the goals of care usually equal to maximizing time left - that usually means aggressive treatments . When we become older and/or sicker, priorities often change as we know that there is a limit to what medicine can achieve and there is a trade off for most people at that stage. Meaning that aggressive treatment also results in less quality of life with no added benefit in many cases. For a lot of folks it becomes more important to spend the time left with quality instead of focusing of getting more time. When that is the case, people focus on maximizing the quality of time left and that means to integrate palliative care and hospice into the the care plan. For example : if somebody has endstage cardiac disease and decided they do not want to go back to the hospital because they know time left is limited anyways and want to focus on staying home with family and kids, watch some sports and such, they may opt to sign up for hospice care and use some sl morphine for chest discomfort and home oxygen instead of heading to the ER.

A lot of people fall into some middle between "aggressive care = maximizing time" and "palliation/hospice = maximizing comfort".

Shifting thinking from death is giving up hope to death is normal can really help to put things into perspective.