DNR HELP

akulahawkRN, ADN, RN, EMT-P · Oct 26, 2014

From my own experience, DNR orders are very specific as to what is allowed and not allowed. When someone says DNR to me, I think the following:

No chest compression
No artificial ventilation
No Intubation
No Defibrillation/Cardioversion/Pacing
No Cardiotonic drugs

If the intervention is not in one of the above categories, then it's probably allowed. A POLST allows for more flexibility and usually spells out what is allowed and not allowed more clearly.

To me, if a patient has an order that basically says "comfort care only" then my interventions are going to be simply to provide for comfort. Your facility/employer should have a specific policy for what is included in "comfort care" measures and it should be very clear about that.

It may be policy to not transfer to a hospital as the patient will not benefit from that transfer if the hospital isn't going to provide any interventions beyond what you can already provide. In those instances, such a transfer would mean that the end result of those transfers are that the patient passes at the hospital and not at your facility.

If the patient is refusing care but doesn't have an order that limits care, you'll need to document the refusals very well and accurately. EMS usually allows people to refuse care up to the point where they become unconscious or altered as at that point, for them, the patient then can be treated under implied consent. Your facility/employer likely has a policy about patients that refuse care when mentally competent and then at some point loses that competency, even though there's no specific order limiting care.

Within that kind of policy is where you'll find your facility's/employer's directives and therefore that's the policy you should look for to find the answer that's specific to your situation.

817nurse · Oct 26, 2014

Always remember: DNR doesn't mean "do not treat," it means "do not resuscitate."

A patient who wants no measures taken might be served by a palliative care consult. Pallative care is not the same thing as hospice. It is comfort care at any stage in the disease process, living or dying.

DNR patients can still be hospitalized or 911'd out of the nursing home.

akulahawkRN, ADN, RN, EMT-P · Oct 26, 2014

Always remember: DNR doesn't mean "do not treat," it means "do not resuscitate."
A patient who wants no measures taken might be served by a palliative care consult. Pallative care is not the same thing as hospice. It is comfort care at any stage in the disease process, living or dying.
DNR patients can still be hospitalized or 911'd out of the nursing home.

This concept, in my own experience, is often completely lost by a lot of care providers. I have taken many DNR patients to the hospital for care that wasn't considered resuscitative within the constraints of the DNR orders. I've taken patients that were heading towards septic shock to the hospital where they'd get antibiotics, fluids, etc.

Unfortunately this is a problem among those in EMS. I would suspect that quite a few "911" providers equate DNR with Do Not Treat. They just don't have the available options that would allow them to provide good care outside of the resuscitation arena.

Palliative care is an excellent resource for patients that are on comfort care only. OP, I hope that you have someone available to you that is well versed in palliative care. It's not hospice... though I suspect that the two services would (and often do) work very well together.

CT Pixie, BSN, RN · Oct 26, 2014

I've sent out DNR patients to the ED. DNR means just that, do not resuscitate, not do not treat as the others have said.

Some of my residents have DNRs in place as well as a do not hospitalize for any reason order. Those are the only ones we do not send out and treat as well as we can in house. I can say that I've had a patient who was DNR and do not hospitalize (she was of sound mind and in charge of her own decisions) who fell and broke her hip. It was all of 2 minutes in pain that she resinded her do not hospitalize order and off she went to the ED.

kiszi, RN · Oct 26, 2014

In the absence of a do not hospitalize order, I would look at things on a case by case basis. Have a discussion with the patient, doctor, and family to decide whether or not to send them out. I am coming from a home care background where the philosophy is to treat in the home to the full extent possible, and the NH is these residents' home.

Now, for emergent issues like the hip fx Pixie mentioned above, I would of course recommend a transfer.

Red Kryptonite · Oct 26, 2014

Unfortunately this is a problem among those in EMS. I would suspect that quite a few "911" providers equate DNR with Do Not Treat. They just don't have the available options that would allow them to provide good care outside of the resuscitation arena.

I just wish they wouldn't act like such jerks when called into situations with DNR/palliative/hospice involvement. There have been times I wanted to just get in their faces and say, "Look, you have your job with its policies and rules, and we have ours. We have to follow ours just like you do yours. Whether you like that or not is not our fault, so suck it up and act like an adult!" It's just so unpleasant and unhelpful to get EMTs with an attitude when you have no choice but to send someone out.

Raviepoo · Oct 26, 2014

I worked with a person in LTC who did not want ANYTHING done at all. The person was was adamant about that over a long period of time. The person ended up getting a "Do not hospitalize" order. Still, if this person's O2 sats dropped, we treated the problem. We just didn't take the step of calling an ambulance. We had a legal document stating that they could not be given CPR and another one stating that they could not be sent to the hospital. We did not have a legal document stating that the person could not be given antibiotics or oxygen. Every individual is different and you have to honor their individual wishes.

firstinfamily, RN · Oct 26, 2014

All the above apply, however, you need to know what your states DNR orders are. The social worker for your facility should be able to clarify this for you. Here in the state of MD, we have two categories of DNR---one allows use of tube feedings and antibiotics, the other allows nothing. If the pt arrests then you do nothing, but each patient should have a discussion with the attending MD to clarify their wishes and understanding of what DNR means. In LTC we had "healthcare agents" who were in charge of the patient's decisions, or if the pt has a medical POA that person should be in the loop as far as the DNR. There are also Advance Directives that the pt has completed before they got sick that should state what they want done and who should make decisions for them if they are not able. It is very confusing, I long for the days when it was a simple DNR. I also have sent DNRs out to the hospital for treatment as DNR does not mean you do not treat. The attitudes of some of the EMT people were so disgusting. They would act like it was a pain for them to be used as a transport system for someone who was sick. I reported some of them to the company who we used, as the patient should be treated with respect whether they are a DNR or not. As I started out, your social worker should be able to help clarify these for you, get a copy of an blank DNR form and study the classifications. Perhaps if you are having problems with this other staff are as well and there needs to be an in-service to help everyone understand them.

ktwlpn, LPN · Oct 26, 2014

This is why advance life care planning is so important. The number of people who don't know the difference between "full code" "DNR" is astounding. Everyone thinks they know what a code is and they believe their 89 yr old demented mother will pop right back up because they see it on TV.

Our palliative care staff start the dialogue soon after admission. You can open this dialogue with your residents and their loved ones, you don't need a palliative care or hospice care nurse to do it. Read their advance directives, speak to the resident if they are alert. Ask the family to consider their loved ones wishes.Every elderly person in LTC has experienced loss and probably cared for their own loved ones. They have usually made some comments in the past about their own end of life. We have to focus the family away from themselves and towards their loved ones stated wishes and support them because they often feel like" doing nothing is letting momma die". Explain that DNR does NOT mean do not treat-it's really just the opposite. If you think the resident is really tanking ask the physician for comfort meds along with whatever treatment course has been decided upon. If you are treating a pneumonia a little morphine can be very helpful and it's not going to do the resident in.

Our palliative care specifies "no hospitalization except for fx/laceration" but we have had more that one family member choose to send their loved one out for IV antibiotics and fluid resuscitation.Many people don't condifer that as true resus and artificial feeding no matter how much education we give them.Can't take it personally.

TardisMom · Oct 27, 2014

At my facility we tend to put orders in for residents who want palliative care as "Comfort measures only, do not hospitalize except for trauma, no IVs, no weights, no labs." If a person is just a DNR that simply means no CPR but they still go to the hospital if they reach a state where we cant treat in house.

AnnieOaklyRN, BSN, RN, EMT-P · Oct 27, 2014

This concept, in my own experience, is often completely lost by a lot of care providers. I have taken many DNR patients to the hospital for care that wasn't considered resuscitative within the constraints of the DNR orders. I've taken patients that were heading towards septic shock to the hospital where they'd get antibiotics, fluids, etc.
Unfortunately this is a problem among those in EMS. I would suspect that quite a few "911" providers equate DNR with Do Not Treat. They just don't have the available options that would allow them to provide good care outside of the resuscitation arena.
Palliative care is an excellent resource for patients that are on comfort care only. OP, I hope that you have someone available to you that is well versed in palliative care. It's not hospice... though I suspect that the two services would (and often do) work very well together.

Where are you getting your information? I work in both nursing and EMS and we are able to follow DNR orders, the fact of the matter is in the US we are afraid to let nature take its course. Lets save the patient until we cannot anymore is the view point, lets ship them out to the hospital so they can die there instead. Patient's who are DNR and who are actively dying should not have to be scooped out of their warm bed, placed on a cold uncomfortable stretcher, taken outside sometimes during the winter, receive a bumpy ride to a hospital so they can sit in a noisy ER and die! I have been to nursing homes countless times where they couldn't find the DNR, the DNR is not properly filled out (even including a signature) etc.

We in EMS are well aware of the difference between DNR and do not treat; I am not sure where you are going with this. If we have a DNR patient who needs fluids etc we do not deny them that; however I will not put a DNR patient on pressers or intubate them etc, those are extremes. A DNR patient who is hypotensive is trying to die, LET THEM, there is a reason they are a DNR. I find nursing homes often call us for dying DNR patients because the NURSES don't know what to do!!!

HPRN