Not so long ago someone here wrote asking what was the point of caring for a DNR/Hospice patient when there were people who wanted to live that needed caring for? It was quite a lively discussion.
Just wanted to say that last night I had the honor and privilege of being present when two of our hospice residents passed over. It's a truly moving and uplifting experience to share this journey with them. I Hope the original poster of that message is still reading.
Ok...a little on topic, a little off topic. Why do some of you--who I assume are relatively healthy--have DNR papers already? Are you a DNR whenever you are hospitalized? Or are you talking about a well-written living will that would go into effect if your chances of meaningful recovery are slim?
I've seen some patients with CAD and DM get resus'd and leave the hospital to go home in fairly good shape. There's no way I would be a DNR right now.
I guess it depends on your perspective. I have had this discussion with coworkers before and we are all different. I have a coworker who says, "Well, Stephen Hawking seems happy enough, right? Being totally disabled wouldn't be the worst thing ever, I'd just like to be alive," and then you have people like me who say, "I don't want to live if I need serious help. If I can't go to the bathroom by myself, communicate well with others, and feed myself, I don't want to be alive."
I really don't want to be alive if there's a possibility that means I'm going to be an anoxic brain injury living in a SNF/LTACH my whole life, which is a real possibility when someone goes into cardiac arrest and loses that blood supply to his/her brain. I'm just not willing to risk it. I don't think death is the worst thing that can happen to a person - I think being catastrophically brain injured is much, much worse. I would rather be dead than live with the deficits I see in a lot of my post-codes. Do some of them get full functioning back? Oh yeah, definitely. I have had a couple recently with no deficits at all. I would just rather die than roll the dice like that. No code = 100% chance of being dead and 0% chance of permanently, irreversibly disabled, after all.
Also, you can't kill patients, so an advanced directive that says, "If I need permanent, significant nursing care after being resuscitated, just go ahead and push a lethal dose of IV morphine, then IV potassium just to be safe" isn't going to fly. Maybe if that sort of advanced directive were possible, I'd be totally fine with being coded.
That's what happens when people read your initial post, the first couple pages of outraged responses (pile on, or not) and don't stick it through til the end.
Thank you for this post, I have apologized and apologized, requested the topic to be closed...and yet...were still focusing on the topic. sigh. I have got so much to learn.
I can relate and it's exactly how I feel about it. I had nightmares about the Terry Schiavo situation.
In the 80's we did not know exactly how HIV and Aids was being spread. The blood supply wasn't being tested like it is today. When I went in to deliver my child, I was afraid I would be given "routine blood." Yes, that use to happen. I refused to sign paperwork allowing them to give me blood. I even put down I was JW, hoping that would solve the argument. It "xxssed" off my Dr who came in and had a few words with me. He did not agree with me, and said he would give it to me anyway. And I told him that if he did and I got AIDS, I would sue his butt off. Cause I rather die on the table, then die a slow death.
I honestly think it's inhumane to keep the shell going and I have a real fear of being stuck that way. Like calivianya said, it's not like if you get in that state they can give you potassium,etc. DNR is the only option to ensure it doesn't happen.
Ok...a little on topic, a little off topic. Why do some of you--who I assume are relatively healthy--have DNR papers already? Are you a DNR whenever you are hospitalized? Or are you talking about a well-written living will that would go into effect if your chances of meaningful recovery are slim?
I've seen some patients with CAD and DM get resus'd and leave the hospital to go home in fairly good shape. There's no way I would be a DNR right now.
I am under 30 but I have a DNR for certain instances. My living will states that I am a DNR "if I have a terminal condition, or am in an irreversible coma, or a persistent vegetative state that my doctors reasonably believe to be irreversible or incurable".
But those are the only instances I have a DNR in place for at this point. When I'm much older, maybe reaching 80 or so, I will have a general DNR where that will be my wish no matter the circumstances.
For now though, My DNR is simply for things I have personally (just for me) decided are things I do not wish to wake up for.
Thank you for this post, I have apologized and apologized, requested the topic to be closed...and yet...were still focusing on the topic. sigh. I have got so much to learn.
cholmes, I went back and read your post on DNR patients (the whole thread). Personally, I think you've earned a very high standing in the estimation of a lot of the veteran posters and the admiration of some newer posters (like myself) for your teachable attitude, not to mention the ability to keep a cool head and remain professional in the face of what turned into a bloodbath. I would like to believe (and I think I'm correct in this) that hppy is not intending to continue the chastisement, but is hoping to spark a new discussion for the benefit of other nurses who may have fostered feelings similar to yours but haven't been as open about it. Granted, I think that calling you out (in a way of speaking) was a little untoward, but I doubt it was meant in a punitive way.
You've come through a tough time; don't take this new thread personally. Keep your head high knowing that you earned the respect of a great many AN-ers for your conduct. Kudos, and keep learning!
Comfort care patients are some of my favorites to work with. It's a refreshing change from the keep someone alive no matter what mentality. Sometimes comfort gets pushed by the wayside when we're so focused on treatment.
I recently had a situation where a patient's DNR/DNI orders contributed to a delay in emergency care. I let the patient's code status lead my decision-making process and didn't act as quickly as I think I would have acted with a full code patient. As I was hemming and hawing about whether the situation was worthy of an EMS call (the provider wasn't readily available to consult at the time, another issue in and of itself), I reminded myself that DNR doesn't mean Do Not Treat. The patient's POLST didn't specifically state Do Not Hospitalize, so I opted to send the patient in. I really wished I had a better advance directive in this situation. The patient is terminally ill but family isn't ready for hospice yet. Those are the toughest kinds of DNR patients, IMO.
I have worked with a lot of end-of-life patients in the hospital. A lot of the time they come in for palliative treatment, such as for COPD exacerbations, UTIs, etc., even though they are staunchly DNR. They are the kind of people who want to die peacefully, not gasping for breath or writhing in pain, or having to endure broken ribs even though the outcome was most likely to be unfavorable.
I had one gentleman come in for some evil cellulitis who did his darnedest to try to get me to kill him with his painkillers. I wanted to help ease his transition, but man, that one hurt my heart. If assisted suicide had been an option, I would have campaigned for it for this guy. He was precious, and suffering so badly. He even wanted me to stop giving him his anti-platelet, hoping for the "big one."
Anyway, easing suffering is just as important to me as is treating the disease. If a patient opts out of treatment (after informed consent), for WHATEVER reason, I try to respect their wishes while keeping them as comfortable as possible. It really makes my day when I get someone comfortable enough that they sleep for a few hours.
At the last nursing home I taught clinical in, they had explicit forms for each resident, signed either by the resident or their HCPOA at the time of admission, that laid out exactly what they wanted done. I loved it. Having that piece of paper circumvented a lot of ethical dilemmas and moral anguish. It also made the transition easier on their loved ones when it was time to move on to Hospice care and withdraw curative treatment.
I love my little old people. It really hurts me sometimes when I see a coworker not treat a symptom that is causing a patient discomfort or distress simply because they are DNR. We have a "come to Jesus" talk and they usually end up seeing things my way.
I guess it depends on your perspective. I have had this discussion with coworkers before and we are all different. I have a coworker who says, "Well, Stephen Hawking seems happy enough, right? Being totally disabled wouldn't be the worst thing ever, I'd just like to be alive," and then you have people like me who say, "I don't want to live if I need serious help. If I can't go to the bathroom by myself, communicate well with others, and feed myself, I don't want to be alive."
I really don't want to be alive if there's a possibility that means I'm going to be an anoxic brain injury living in a SNF/LTACH my whole life, which is a real possibility when someone goes into cardiac arrest and loses that blood supply to his/her brain. I'm just not willing to risk it. I don't think death is the worst thing that can happen to a person - I think being catastrophically brain injured is much, much worse. I would rather be dead than live with the deficits I see in a lot of my post-codes. Do some of them get full functioning back? Oh yeah, definitely. I have had a couple recently with no deficits at all. I would just rather die than roll the dice like that. No code = 100% chance of being dead and 0% chance of permanently, irreversibly disabled, after all.
Also, you can't kill patients, so an advanced directive that says, "If I need permanent, significant nursing care after being resuscitated, just go ahead and push a lethal dose of IV morphine, then IV potassium just to be safe" isn't going to fly. Maybe if that sort of advanced directive were possible, I'd be totally fine with being coded.
Excxxxactly. I am 30 years old and have a DNR. Just let me go into the light please.
I just feel like it needs to be said that a DNR isn't the same as an advanced directive or living will.
Someone who has a DNR has to bring all the paperwork with them when they're admitted, a new order has to be written and it has to be signed by two MD's as well as only being valid for 30 days. (Don't know about all states, but thats how it works here)
No CPR, no defibrillation if a DNR codes. It doesn't mean "Let me die" it means "Don't bring me back if I die".
I just feel like it needs to be said that a DNR isn't the same as an advanced directive or living will.
Someone who has a DNR has to bring all the paperwork with them when they're admitted, a new order has to be written and it has to be signed by two MD's as well as only being valid for 30 days. (Don't know about all states, but thats how it works here)
No CPR, no defibrillation if a DNR codes. It doesn't mean "Let me die" it means "Don't bring me back if I die".
Absolutely. Maybe it's my post that needed clarification on this? my DNR for those instances I listed are not just to "let me die" but rather it is if those are the circumstances, and I do pass away, then I am a DNR.
Absolutely. Maybe it's my post that needed clarification on this? my DNR for those instances I listed are not just to "let me die" but rather it is if those are the circumstances, and I do pass away, then I am a DNR.
I'm guessing glycerine might be referring to you saying that your DNR order was in your living will. At least in the states I'm familiar with, a living will that expresses wishes to be DNR is not itself a valid DNR order. I find many patients are under the impression that by putting their wishes to be DNR in their living will, that this means they are now DNR, which is not the case. A living will is completed by a lawyer, and unless that lawyer is also a Physician they are not legally qualified to discuss the benefits, considerations, prognosis, etc of being DNR. A living will can be used by the Physician to determine the patient's wishes, but then again so can just telling a family member your wishes or really any other way of communicating those wishes.
I've had a few patients who are resuscitated and complain because they had a living will that said they were DNR, unfortunately it's only at that point they are told that a living will DNR is essentially useless as a way of ensuring you won't be resuscitated.
I caught this thread and then went to read the original thread and here I am again. I can understand a misunderstanding of what a DNR is, especially since I have worked mainly LTC for the duration of my career. I think a lot people see DNR and associate it with the elderly and end of life care, I can only assume that the OP was having that mindset with mentioning the Hospice pt as well. Even then, there is quote a difference between Hospice and LTC IMO.
I have had a very small handful of Hospice pts in the LTC facilities I've worked and I very rarely had them on my halls...altho my expertise (if you will...perhaps specialty?) was Alzheimer's care stages 1 and 2. Anyway, I have a story that I feel compelled to share with the OP cholmes, partially for my own personal feelings at the moment but also to give a perspective from someone who has worked health care AND has had a loved one on Hospice care.
My grandmother passed away this Friday at a Hospice House facility, as I said I had never had much interaction with Hopsice pts so this experience was new for me in a professional and personal way. My grandmother spent 5 days in this facility and having been out of the workforce for a few years I was horrified at the thought of her being in a facility. I was pleasantly surprised that the facility itself was very nice but I was more so amazed at the quality of care she received from the amazing nursing staff. My grandmother was sedated for the duration of her stay and I don't believe she knew that any of us were there but she was treated the utmost dignity and respect and that extended to us as well and that meant the WORLD to us.
Being a CNA and speaking to the staff about my grandmothers care was a bit scary for me because I expected to be met with resistance (You're just a CNA...) and I was pleasantly surprised. They allowed me to help care for her and didn't seem to mind my consistent barrage of questioning over her current condition, medications, etc.
In the end, my family called me into the room before the staff and I got to sit with her, hold her hand and feel her pulse slip away and announce to the room full of my family that she was gone and at peace...
Hospice nurses are amazing people and there is no greater sadness and feeling of peace at the same time than to be present for the last moments of a persons life. It takes a VERY special person to care for these people AND be able to make the families just as comfortable as the pts. I want you to think of how you would feel if this person were your loved one and use that perspective to gain understanding. It's not easy to do unless you've experienced it first hand either in a profession or personal environment.
As to the DNR, it is actually quite common for people to misunderstand what it actually means, I didn't understand it fully when I first started my career either. I'm glad that you have gained some new perspective on that here.
calivianya, BSN, RN
2,418 Posts
I guess it depends on your perspective. I have had this discussion with coworkers before and we are all different. I have a coworker who says, "Well, Stephen Hawking seems happy enough, right? Being totally disabled wouldn't be the worst thing ever, I'd just like to be alive," and then you have people like me who say, "I don't want to live if I need serious help. If I can't go to the bathroom by myself, communicate well with others, and feed myself, I don't want to be alive."
I really don't want to be alive if there's a possibility that means I'm going to be an anoxic brain injury living in a SNF/LTACH my whole life, which is a real possibility when someone goes into cardiac arrest and loses that blood supply to his/her brain. I'm just not willing to risk it. I don't think death is the worst thing that can happen to a person - I think being catastrophically brain injured is much, much worse. I would rather be dead than live with the deficits I see in a lot of my post-codes. Do some of them get full functioning back? Oh yeah, definitely. I have had a couple recently with no deficits at all. I would just rather die than roll the dice like that. No code = 100% chance of being dead and 0% chance of permanently, irreversibly disabled, after all.
Also, you can't kill patients, so an advanced directive that says, "If I need permanent, significant nursing care after being resuscitated, just go ahead and push a lethal dose of IV morphine, then IV potassium just to be safe" isn't going to fly. Maybe if that sort of advanced directive were possible, I'd be totally fine with being coded.