DNR HELP

kbrn2002, ADN, RN · Oct 27, 2014

Quoted from above post...I find nursing homes often call us for dying DNR patients because the NURSES don't know what to do!!!

No argument from me. We as LTC nurses often don't know what to do. Because of missing or poor health care directives, because of very old code status forms, because the POA for healthcare has the right to change their minds about any previous advanced directives, because we can't reach the POA to confirm their wishes. In these situations it is safer for all involved to just transfer out to a higher level of care. As others have said DNR doesn't mean do not treat and there may be more that can be done at the hospital than we can do in a SNF.

akulahawkRN, ADN, RN, EMT-P · Oct 27, 2014

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

I get my information from the same place you do... personal experience, unfortunately. We have even had many of the same experiences. You and I are actually basically on the same page about how to treat these patients. A hypotensive DNR patient isn't always trying to die. That DNR patient could very well have a very treatable infection. Providing fluids and antibiotics isn't always outside the typical DNR orders. The problem with providing fluids is that fluids may or may not be considered a "cardiotonic drug" whereas dopamine and dobutamine certainly are, as far as a DNR order is concerned. This is why I much prefer the POLST to a DNR. I certainly agree that actively dying patients that are DNR should be made comfortable and allowed to pass naturally.

It used to be that people that were actively dying were easy to spot. With modern medicine, we can push off and slow down the dying process that it's often difficult to truly determine when a person is actively dying until death is nearly imminent.

Not all EMS providers equate DNR with Do Not Treat. You and I are among those that understand the difference. I hope your EMS employer/system also understands the difference as well. I have seen EMS transport protocols specific to DNR that essentially state that DNR patients will not be transported with Lights and Siren, regardless of the reason.

DNR orders don't just affect peri-code situations. However we in EMS are typically going to be called to deal with people that are very much in that situation and this ties our hands considerably. Patients that just have a UTI that are starting to go septic, patients that display signs of anaphylaxis, patients that have reactive airway diseases... they are all affected by a DNR order in some manner.

tyvin, BSN, RN · Oct 28, 2014

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0CC4QFjAC&url=http%3A%2F%2Fwww.nolo.com%2Flegal-encyclopedia%2Fdo-not-resuscitate-orders.html&ei=4RhPVM_BLITsoAS0-YHACA&usg=AFQjCNFAYOIoq62b8cB6QwlvD1TSdU0a8g&sig2=E6FHrHUlKqamnODTNHVFnw&bvm=bv.77880786,d.cGU

This link is a good read on DNRs. For instance in Florida, if the DNR is not written

on yellow paper, it's not legally recognized in that state. The link also provides links to material if further reading is desired.

:)

tyvin, BSN, RN · Oct 28, 2014

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

Oh so heartfelt painfully true. When working with nurses who have no idea what they're doing while dialing 911 for an actively dying patient who has a DNR that makes it clear to let them go and not to call 911 when their time comes; I spit fire and scream at them to hang up....I really didn't but you know I thought it. Please people, get it together and know your DNRs and POLSTs. It should be mandatory that all nurses know the patients/residents advance directives. :)

RN_2012, BSN, RN · Oct 28, 2014

DNR, to me, means nothing is done once they are no longer with a pulse. We have DNI or people who also do not want to be intubated, which is not the same as DNR. Some people are both DNR/DNI.

RN_2012, BSN, RN · Oct 28, 2014

My experience as an RN in nursing homes and now one in an acute care facility is those that are FULL codes are sent out when they are circling so the nursing home doesn't have to code them. I know I sent them out faster, then someone who had a DNR. DNR means I do not attempt to bring them back after they no longer have a pulse. If you are in respiratory failure with a DNR, you might still go out depending on the family and doctors wishes. A full code, is going out and not waiting for the in house doctor to get around to her/him.

BR157 · Oct 28, 2014

To they OP, only the P&P manual for your facility can correctly advise you. Each state, county and facility can have its own regulations, rules and paperwork. There are also exceptions to every thing so don't just look at the color of the paper but also read it thoroughly for what has been added or removed on it. Keep it readily accessible and highlight the exceptions somewhere visible. If there is something that is vague, get it clarified by your charge and the doctor. It is not made less vague in writing, don't just take someone's interpretation of it, push for a written clarification.

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

Normally I am the first to defend Paramedics but I can not do that with your post.

You contradict yourself here by saying you give fluids to treat and then you don't because YOU think they are dying. This is not for you to decide. The patient HAS A PULSE. Call the doctor. There is no shame in this and NO PARAMEDIC or ER NURSE should ever criticize nursing home or hospice nurses for doing as much as they can with very little in very difficult situations.

What is "actively dying"? If they are "actively dying" then that patient is not comfortable. The patient also still has a PULSE and still needs to be treated either "actively" or comfort measures addressed immediately. Unfortunately sometimes the only way to address comfort measures is to take the patient to the hospital where they can be initiated or the patient can be moved to a hospice room or facility. Not all facilities are equal when it comes to what they can provide for "comfort measures" due to the limitations of their facility's classification. It is not the fact of the nurses who work there that their facility is limited for medications and drips unless special arrangements are made through Hospice providers.

You need to address the condition of your ambulances and the way your EMTs or Paramedics treat patients. Surely they can put a few blankets on the patient, heat up the ambulance and take more care when moving them. Dying in pain in a nursing home or at home is not much fun either for the patient or the family or caregivers to watch helplessly when the EMTs or Paramedics refuse to transport a "DNR".

Intubation is also a possibility if it makes the patient more comfortable while whatever acute situation is addressed. Patients with DNRs reverse them all the time for the OR where they are probably intubated. You can also be a DNR on a ventilator in the ICU just in case your HEART STOPS. Until that happens, you can be TREATED. In some situations intubation might be the extreme but that is not for you to decide. These are personal decisions which are made by the family and/or the patient along with their doctor.

the fact of the matter is in the US we are afraid to let nature take its course.

No, we are more about following rules which are designed to protect the public in general especially when it comes to some who feel it is THEIR RESPONSIBILITY TO DECIDE WHO LIVES or DIES after just a certificate or Associates degree and without knowing anything about the patient. Some just get on their own power trip. I hate to say this about EMS but there are some Paramedics who are more concerned about leaving the comfort and warmth of their bed to respond to some gomer call at a nursing home. That is a stretch for me to say since I have been censored here for defending Paramedics on several issues. For ER nurses, while you are complaining about "another DNR" in your ER, you are not focusing on patient care.

BR157 · Oct 28, 2014

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0CC4QFjAC&url=http%3A%2F%2Fwww.nolo.com%2Flegal-encyclopedia%2Fdo-not-resuscitate-orders.html&ei=4RhPVM_BLITsoAS0-YHACA&usg=AFQjCNFAYOIoq62b8cB6QwlvD1TSdU0a8g&sig2=E6FHrHUlKqamnODTNHVFnw&bvm=bv.77880786,d.cGU
This link is a good read on DNRs. For instance in Florida, if the DNR is not written
on yellow paper, it's not legally recognized in that state. The link also provides links to material if further reading is desired.
:)

That link is nonspecific and of very little use. You need to be familiar with your own state, county and EMS regulations and protocols. Some have several different levels and many are designed around the patient. Just the color of the paper means very little when the exceptions can be written on it.

Oh so heartfelt painfully true. When working with nurses who have no idea what they're doing while dialing 911 for an actively dying patient who has a DNR that makes it clear to let them go and not to call 911 when their time comes; I spit fire and scream at them to hang up....I really didn't but you know I thought it. Please people, get it together and know your DNRs and POLSTs. It should be mandatory that all nurses know the patients/residents advance directives. :)

What is "actively dying"? If they are "actively dying" they are probably not comfortable. Maybe the nurses believe it is inhumane to have a patient suffer when much more could be done at another facility or the patient can also be moved to hospice. I am a big supporter of Hospice but sometimes you have to go the round about way to get there. Be an advocate for a comfortable dying process instead of supporting "actively dying".

A DNR makes nothing clear until THE HEART STOPS! Patients can be treated. What you might believe to be "actively dying" might be a little fluid overload or PNA which can be treated. If a patient is allowed to "actively die" and suffer, YOU should be prosecuted to the highest extent of the law for patient abuse and neglect to perform your duties.

I can easily see why families and some doctors are so reluctant to place a DNR status on the patient.

It is better for those like the OP who asks questions, although they should be directed at the proper sources, than those who believe they know it all about dying. No one blanket statement covers all the situations, all the patients and all the exceptions.