DNR means what???

subee, MSN, CRNA · Sep 29, 2011

"DNR" is vague term. Why DNR forms need to be more specific. However, IMHO, most people who sign a DNR form, do NOT want to be sent a acute care facility to be resuscitated - it violates the spirit of patient's desire. We're just going to have a lot more court cases to set precedents and I'm sure it will end up with a 25 page DNR form that has to be renewed every 48 hours! Every case is different, but if your patient were my mother who expected to die in her bed in the nursing home, I would never allow her to be sent to hospital. Do you expect the hospital to discharge this patient in better shape?

SkylerW · Sep 29, 2011

DNR means no action is to be took during a cardiac/pulmonary arrest. Which includes Chemical, Mechanical, and Physical treatments. DNR doesn't mean do not treat, but usually DNR= Comfort care Advanced , and Directive means= Do not code, and prbly do not intubate it depends on the patients wishes. Your facility may have different policies though.

SonorityGenius · Sep 29, 2011

in this case did the patient also have DNH? Do not hospitalize? If not than you did the right thing and sent patient to the ED.

ProgressiveActivist, BSN, RN · Sep 29, 2011

A DNR means to allow their natural death if death is imminent. It does not mean that we allow a person to suffer and die from inadequate medical care.

Altra, BSN, RN · Sep 29, 2011

I agree that DNR does not necessarily mean do not treat. But I do wish that LTCs and patients' MDs would be much more frank with patients and their families to draw out what their wishes really are.

This comes from my ER/ICU background ... but in my experience too many patients are sent to the hospital to die. The reasons for this are many. LTC staffing. Lack of clarity about DNR status. Incomplete information given to patients/families about what scenarios are likely to occur given the patient's condition, and what the options are to treat or not treat those scenarios. Etc. Etc.

I have simply done too many septic workups on shivering, contracted, 85+ year olds with stridor you can hear down the hall ... and while we may spare them the indignity of an actual code ... they spend their last hours being transported out of their LTC home, in an ambulance, to a bright, noisy ER while strangers poke & prod them with needles and catheters and monitor leads ... all for naught.

cloverleafLPN · Sep 29, 2011

Better shape...neh.

Its inevitable we are all going to die. Maybe not now...maybe not in ten years.

Comfortable...yes...maybe exchange and review meds, of course.

That to me is what the hospitals job is, to provide care and acute assitance. I was adviced that DNR meant DNR....which I completely understand. No CPR. I just don't see that as a legit excuse to just chock it up to the good Lord to suffocate somone. Which is in essence what would have happened.

I just dont understand why other healthcare workers who you collaborate with take offense to DOING their job!! By all means, every person and family has a right to refuse and like it or not we have to abide. I just don't understand the concept of not treating acute cases just because they are DNR. Especially when the said PT isn't relieved by other efforts and options before having a MD evaluate personally.

We all know Hosp. have much more access to things than LTC does. Its not right....but thats how it is.

Altra, BSN, RN · Sep 29, 2011

That to me is what the hospitals job is, to provide care and acute assitance.

By this logic, all declines in, say, respiratory status (increased O2 needs, worsening lung sounds) are "acute" situations.

What I'm saying, and literally begging you to consider, is that not all of these "acute" situations should be treated by transferring the patient to a higher level of care. Not every LTC death will be a patient passing quietly while sleeping, and it is unreasonable to expect otherwise.

darkangel83 · Sep 29, 2011

By this logic, all declines in, say, respiratory status (increased O2 needs, worsening lung sounds) are "acute" situations.
What I'm saying, and literally begging you to consider, is that not all of these "acute" situations should be treated by transferring the patient to a higher level of care. Not every LTC death will be a patient passing quietly while sleeping, and it is unreasonable to expect otherwise.

AGREED!

In our ER we are using a more specific method of determining final wishes with several categories including resuscitative care, medical care, and comfort care. So far, it is working out far better than your typical 'DNR' and 'Full Code' designations. We are really encouraging our LTC facilities to follow a similar format as a lot of the population do NOT understand what it means to be a 'full code' or a 'DNR' and we are receiving a lot of residents from LTC facilities who never wanted to be transferred to the hospital in the first place...which we are finding out AFTER the fact.

cloverleafLPN · Sep 29, 2011

Not every LTC death will be a patient passing quietly while sleeping, and it is unreasonable to expect otherwise.

I do agree, people in the dying process should be given dignity and respect to pass however they should choose wether that be comfort care, full code, dnr, or whwd.

My point is, I realize not every pt/family wants these measures. But, I cannot accept "DNR" as a reason to not have an MD physically assess and treat with more resources when this is not what the Pt/Family wants. I realize that some pt/family do not want transfers and hospitilization...but when they do...why is it at someone elses discretion to act as if they are a burden because they are a DNR. ER/LTC/MD/Caregivers all included.

We do not treat DNR's as people who want comfort care. Comfort care orders must be in place...maybe this is where some confusion is coming in. I realize not all DNRs should be transfered...those however have Comfort Care only measures in our facility.

Everyone is free to their opinion...this is just my take on the difference between what pt/family wants vs what some health care providers take as they don't want anything, and the attitude of DNR...whats the point. When that specific persons DNR does not state comfort only. I think their should be a universal discretion between the two. Obviously this differs widely from state to state. Acctually kind of interesting...but also very scary at the same time.

nurse2033, MSN, RN · Sep 29, 2011

You are right. The patient deserves medical care and relief from suffering.

ckh23, BSN, RN · Sep 29, 2011

I agree that DNR does not necessarily mean do not treat. But I do wish that LTCs and patients' MDs would be much more frank with patients and their families to draw out what their wishes really are.
This comes from my ER/ICU background ... but in my experience too many patients are sent to the hospital to die. The reasons for this are many. LTC staffing. Lack of clarity about DNR status. Incomplete information given to patients/families about what scenarios are likely to occur given the patient's condition, and what the options are to treat or not treat those scenarios. Etc. Etc.
I have simply done too many septic workups on shivering, contracted, 85+ year olds with stridor you can hear down the hall ... and while we may spare them the indignity of an actual code ... they spend their last hours being transported out of their LTC home, in an ambulance, to a bright, noisy ER while strangers poke & prod them with needles and catheters and monitor leads ... all for naught.

That's interesting. I just read an article in the philadelphia inquirer the other day about a local hospital that has place a palliative care nurse in the ER and she works with a physician that is board certified in both emergency medicine and palliative care. I found the article to be quite intriguing.

http://articles.philly.com/2011-09-28/news/30213092_1_emergency-department-palliative-care-teams-nursing-home