So Im not a newbie, but Im FARRR from being a veteran...
Im in LTC, great facility, great nurses.
Like all night shifts, we basically avoid calling the MD unless its necessary.
However last night...pt was having some resp distess/possible seiz activity with a stoke high bp and low 02's.
pt was a "DNR"
ER nurse has the gall to ask ((after I spill into report and then state "active DNR"))
and just what are you sending the pt over for....
mmmmkkkkay....let me repeat myself LOW 02, HI BP, RESP DISTRESS, and SEIZ ACTIVITY!!!!
Of course, I didn't say that. I repeated it all back in a very kind-but-snippity manner and then stated "doctors orders" Do you ever fee like some Doctors/Hospitals/EMTs take DNR to far?
I say it like this DNR means EXACTLY that. Its not an excuse to not treat someone wether activily passing or in an acute situation. W/W does not mean not treat. If a pt's family didn't want treatment...they'd say so. Otherwise, its our responsibility as well as everyone involved in their care. Can I get an Amen???
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.
here are some quick examples from my own family, all of whom had dnr's:
my grandmother was 89 and had advanced parkinson's. her mind was good but her speech was impaired.
she made it known that she wanted nothing done but comfort care when death was near. she was given sips of water or her lips wet with a glycerin swab, and that was it. no ivs, no feeding tube, no abx when she got pneumonia. when her cardiac system became overwhelmed, no more water was given. she died that night.
my great-grandmother was 106 and had had several strokes. she had 10 children: two were m.d.s, and three were r.n.s. their conclusion was that grandma wasn't "with it" enough to make a legally binding
choice, and they chose comfort care only. it took a week, but she died at home, in her own bed, surrounded by five generations of her family. she slipped in and out of consciousness that week, was given light non-rx pain meds prn, was not suctioned as she had been before, was not fed, and just slipped away.
my aunt had breast ca., had a dnr, and her adult daughter wanted everything short of cpr done. not my personal definition of dnr. when the time came, my cousin panicked and begged the emts to do cpr.
not sure why they were called???
my mom had two different types of breast ca at the end. she chose to remain at home and have hospice.
her mind went quickly! fortuately, as a lawyer, she knew she had to make her final wishes known soon. everybody was on board except her twin sister. no amount of explaining, persuading, whatever changed her mind. by then, my beloved, funny,wonderful, strong, in charge, mom was gone forever. in her place, was someone none of us knew. aunt ___ stepped right in and tried to begin proceedings to reverse the end-of-life plans my mom had made. one of my lawyer relatives stopped her and the plan was reinstated. but she fought all of every single awful step of the way. "don't give her that morphine!
what if it kills her?":eek: "don't give her that shot! what if she stops breathing again?":eek: "but we don't want her to hurt, do we?":nurse: "but one of these shots will kill...murder her... and then what?"
eventually... the time came. i was with her all that night and when it happened. i had to physically restrain my aunt from beginning cpr. i felt like a beast, my own mom had just died, and there i was.
all my mom had wanted was adequate pain relief, and she got it but it wasn't easy with my aunt hovering.
dnr in that case meant a chemo session to shrink liver size due to a tumor which had popped up, pain control, comfort measures and that was it.
Part of the problem is the false notion that there are only the two opposite ends of the spectrum--do everything and do nothing (DNR). As others have stated, there are a lot of options in between that include treatment of short-term, non-lethal problems; treatment for relief of symptoms; and comfort measures only.
You can have a DNR order and still get glycerin for your chapped lips, or benadryl for a rash or Tylenol for a fever.
What you don't get are treatments directed at reversing the overall disease process (chemo, radiation, perhaps abx, etc.) or heroic measures when the body fails.
DH and I just signed Durable Healthcare Power of Atturney forms that went into a fair amount of detail. The secondary for each of us is a daughter who has two sons with chronic health issues. She understands that in an end-of-life situation, we want the kind of care that will allow us to be as comfortable as possible. For instance, drain abdominal ascites to allow for easier breathing, but don't okay surgery (for that same problem) that is just postponing the inevitable.
You can have a DNR order and still get glycerin for your chapped lips, or benadryl for a rash or Tylenol for a fever.
What you don't get are treatments directed at reversing the overall disease process (chemo, radiation, perhaps abx, etc.) or heroic measures when the body fails.
I don't exactly agree with this.
DNR = Do Not Resuscitate. There is absolutely nothing there that says do not TREAT. It means if I suddenly stop breathing/heart stops beating do nothing. Living Wills are an entirely different beast and THAT is what should be determining what we will/won't do while the patient is still alive. (I'm also a firm believer that your living will is only as good as the family support you have. I have seen many living wills completely ignored once the patient can not speak for themselves. All it takes is a bunch of demanding obnoxious family members and a whimpy MD.)
As a veteran of LTC I can assure many of you that we do all we can to educate families on what a DNR means. I think you would be amazed at how much resistance we get on this. But, after reading some of this I wonder if families aren't getting many mixed messages on what it means to be a DNR, making it impossible for them to make an informed decision. I also think they get so many mixed messages from the media...all the talk of "death panels" the miraculous recoveries from gentle looking CPR on TV, etc.
Specializes in Gerontology, Med surg, Home Health.
We are obligated to follow the wishes of the family and the resident despite our personal or professional opinions. DNR means Do Not Resuscitate. If I find you without a pulse I will not start CPR. If you fall and break your hip, you will go to the hospital. We have a range of advance directives. Some are simple DNRs. Some are do not intubate, do not hospitalize, no IVs, no tube....compressions only--no shock. And, honestly, I'd much rather keep my sick,frail,very elderly residents in my facility where the staff knows them and they know the staff to be treated and made comfortable than to send them to the loud hospital with a bunch of strangers. BUT if the health care proxy says send them, other than telling them what I think, I have no choice but to send them.
So Im not a newbie, but Im FARRR from being a veteran...
Im in LTC, great facility, great nurses.
Like all night shifts, we basically avoid calling the MD unless its necessary.
However last night...pt was having some resp distess/possible seiz activity with a stoke high bp and low 02's.
pt was a "DNR"
ER nurse has the gall to ask ((after I spill into report and then state "active DNR"))
and just what are you sending the pt over for....
mmmmkkkkay....let me repeat myself LOW 02, HI BP, RESP DISTRESS, and SEIZ ACTIVITY!!!!
Of course, I didn't say that. I repeated it all back in a very kind-but-snippity manner and then stated "doctors orders" Do you ever fee like some Doctors/Hospitals/EMTs take DNR to far?
I say it like this DNR means EXACTLY that. Its not an excuse to not treat someone wether activily passing or in an acute situation. W/W does not mean not treat. If a pt's family didn't want treatment...they'd say so. Otherwise, its our responsibility as well as everyone involved in their care. Can I get an Amen???
Anyone have any stories/advice related to this?
DNR means what you described.
However, some LTCs have lengthy options for what the resident or family wants done in the event of some change of condition- from UTIs to fx hips to actual CP arrest.
Even on an acute unit, someone who has a terminal illness, but has an unrelated acute situation come up, usually gets treatment for the unrelated acute problem. Someone with end stage prostate CA would still get treated for a pneumonia...etc.
If someone is actively dying (mottled, respirations changing, BP tanking, etc) there are a lot of gray areas (no pun intended). My mom had high blood sugars (not a diabetic) and urosepsis. The urosepsis was killing her...fast. The blood sugar issue was not going to change that. So, my dad and I opted to not put her through accucheks and insulin (which she moaned through- semi-comatose). I'd seen her lab work. The blood sugar was the least of her issues- and probably a result of the sepsis. Not treating it wouldn't prolong or prevent anything.
I think some of the confusion is what some folks consider "DNR" is what I know as "hospice" -- allow natural death, comfort care, but no acute intervention in the period leading up to death. And I know working in ICU/ER, we get the same little folks from their nursing homes every week or two for UTI/pneumonia/sepsis/failure to thrive/back to UTI....and I've probably asked why couldn't they just let them pass at their home, rather than surrounded by strangers, every orifice with a tube in it, on a vent, pressors, etc. It's not because I'm mean, it's just because we've got docs that will tell you to your face "DNR means I can do any D*** thing I want to them until their heart stops." I've seen DNRs been put on vents, because they didn't know enough to state DNR/DNI -- and then they're in the unit for 2 months, slowly rotting alive, all while the MD gets money every day they're there.
Sure, treat an injury, get them abx and tylenol for sepsis, but come on, when someone's at the end of their life, in their 90's, EF of 20%, end stage COPD/CHF/end stage renal, do you really need to send them to ICU when their kidneys finally stop working? Or is the right thing to consider a Hospice consult and let them pass peacefully, medicated for discomfort, in their own home, educating the family about the patient's condition and that less than 30% of CPR attempts actually result in the patient living to get out of ER or ICU? And of that 30, only 30% of those are alive at the end of a month?
I think we do a very poor job of telling families, "Look, she's not going to get better no matter what we do, let's discuss hospice and end of life." And that's a huge disservice to out patients and their families.
one of the first things i did post-stroke was get in touch with our attorney. he came about 24 hours later and stayed about an hour, just talking. he had been one of my dad's partners and had known me since i was little. he concluded that i was "of sound and rational mind." he drafted a medical poa but didn't think i quite needed any other type of poa quite yet. instead, i have a somewhat archaic document that has fallen pretty much out of favor. it's an aif or attorney in fact document and suits my needs perfectly.
there are days when i can sign my name easily and days or times of day when i can't execute a "k" to say nothing of my entire signature, and the aif gives my husband the legal right to sign my name, then make a / then sign his name/aif. i don't want to give away any power or rights before i have to and he doesn't want to usurp any rights to make decisions and the aif is a good solution for us. with the poa i had for my mom, legally i could have sold her house behind her back, had i been so inclined. i trust my husband with my life. i just don't choose to relinquish any more control than i absolutely must any sooner than i have to. i have an aif for him too, as well as a medical poa. being able to sign for me lifts a lot of pressure from me.
i feel if the aif weren't treated as someone's maiden aunt type of option (does that make sense at all?)
and were instead presented as a viable option, many many more people would make alternative arrangements in case the need arises, and that's the first step, in many cases to a medical poa.
AHMEN! DNR applies when someone is in cardiac or resp arrest. It does not mean stand by and do nothing as a treatable condition becomes cardiac or resp arrest!
You can have a DNR order and still get glycerin for your chapped lips, or benadryl for a rash or Tylenol for a fever.
What you don't get are treatments directed at reversing the overall disease process (chemo, radiation, perhaps abx, etc.) or heroic measures when the body fails.
I just wanted to point out
There is actually such thing as palliative radiation/chemo. We used this a lot in the Hospice that I interned in.
Radiation/chemo has the ability to shrink the tumor(s)
Tumors can be extremely painful depending on size or location (or cause a multitude of symptoms from difficulty breathing to inability to eat/swallow ect). Although the radiation/chemo isn't curative, it functions as comfort care when the pain and symptom relief outweigh the side effects of said treatment.
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.
OMG, this, this, THIS!!!
"DNR" is NOT enough! The dialogue between patient, family, and health care provider, needs to include other possible events besides just cardiac or respiratory arrest!
Sepsis is not really a bad way to go. Pneumonia used to be called the "Old Person's Best Friend" because so many elderly died of pneumonia instead of lingering on and on, tired of living and wishing they could die.
To me, if a person decided that they are ready to die from whatever happens to be their fate, then please don't send them to the ED! Get orders for a morphine gtt, foley catheter, scopalomine patch, colace, whatever it is you need in order to keep them as comfortable as possible in their last days, and for heaven's sake, let them go in comfort with dignity!
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Altra, BSN, RN
6,255 Posts
Excellent article!