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???
But does it also mean that that 98 year old, with severe dementia, diabetes, heart failure, atrial fibrillation, acute/chronic renal failure who now presents because of "fall" and "hip fracture" (broke that hip the third time) - be "treated"? The full works including surgery (assuming Cardiology and Internal Medicine clear him) ??
"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!
But A&O people have DNRs...they're not circling the drain, but end up with acute problems. Just keep them at the LTC with sepsis, pneumonia, or a hip fx, simply because of 3 letters on the front of their chart?
This is exacty what I'm talking about! There is so much "gray area" as said before, that sometimes I think people are mistaken by what DNR actually means and therefore people are DNR and strictly "DNR" aren't treated as they want every medical treatment until a pulse is lost and they are taken from this world...however...I do agree that some people need to be able to pass peacefully where they are...which is an entirely differen matter of family vs medical ethics.
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?
extention question then where i think they should not transport because of experience. 90 y.o. f transfered in from ltc facility for respiratory distress(ish), she had fluid but was handling it well wanted no procedure done. children unlocatable. hospital md does not recognize the dnr from the ltc facility, so totally begins his stuff. the 90 year old woman thrashing in bed, stating dnr and that she wants nothing done respiratory difficultly. so, 90 y.o. woman trying to attack staff (okay, i would too and i did not participate) because she wanted to be left alone. doc deems mental status altered and woman unable to make own decisions. come on, she didnt want him or anyone doing anything she wanted to die. nothing confused about that. so, doc orders ct guided thoro. and what do you think happens to 90 y.o. frail grammy. yep, lung puncture collapse to chest tube??? then restrained because ****** this is all happening, i felt horrid that this woman was going through this. if i want to die and i am 90, man nobody better take me to the hospital. i thought that was inhumane. whatever way it comes about that we are going to go, that is the way it is supposed to be no matter what happens. there are times when the purpose is clearly positive and should happen, and there are clear times when you need to let nature be.
Specializes in Gerontology, Med surg, Home Health.
But A&O people have DNRs...they're not circling the drain, but end up with acute problems. Just keep them at the LTC with sepsis, pneumonia, or a hip fx, simply because of 3 letters on the front of their chart?
DNRs aren't just for gomers anymore :)
I find the term "gomer" to be unbelievably insensitive and highly insulting.
But A&O people have DNRs...they're not circling the drain, but end up with acute problems. Just keep them at the LTC with sepsis, pneumonia, or a hip fx, simply because of 3 letters on the front of their chart?
DNRs aren't just for gomers anymore :)
Exactly what I'm talking about! LTC is also full of people below 60 and are in good health...just need a little help. Heck my grandfather is 70 years old and you better believe when he's sick he's going somewhere. Age is a number...the person and their situation is not and just because you call someone and say "pt has DNR" does not give them the okay to have snappy attitudes and preconceived notions that they are starting to make a bucket list...it's not fair to the patient and IMHO it takes away Tom the ones who aren't in the process of passings care. I just think maybe some people on the other end of the phone should not assume a 60 and up years old in LTC who is DNR is not worth the time of taking to even be evaluated and sent to the hospital. I know it probably does get old seeing all the passing people come thru who want nothing more than to pass quietly, but some are not passing and DNR or even WHWD should not be a bright red dot saying "I'm dying now let me go"
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!
With all due respect - duh! Not sure what people aren't getting about the fact that the LTC nurse can only educate residents and family on the choices they have and the risk/benefits of those choices. After that it is THEIR choice and I am required to do what they instruct me to do. Acute care must have the same problem with the same families as most often the eventually return to us "treated". (This is part of the discord between nursing specialties - we don't always try to see the obstacles the other faces)
Do I agree with you...most certainly. It is a complete tragedy what we do to these little old people who should have been allowed to pass peacefully many years ago. I have some of the most fantastic hospice nurses available to me. I do my best to get the families to at least sit down and talk with them but some outright refuse and become angry and offended at the idea. It is also a tragedy the amount of resources we spend to try to "save" some of these folks. But again - please understand, I don't have the final say in these matters.
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.
my understanding is that there is a big difference between a durable power of attorney for healthcare and your regular poa. the dpoa for health care gives them power to make medical decisions on your behalf if and only if you become mentally and physically unable to make decisions for yourself. coupled with a living will in which you spell out specific wishes regarding medical treatment in any number of scenarios, your wishes have a good chance of being respected. seems like you cover all bases here without giving up legal rights such as you described above in your mother's situation. am i wrong?
my understanding is that there is a big difference between a durable power of attorney for healthcare and your regular poa. the dpoa for health care gives them power to make medical decisions on your behalf if and only if you become mentally and physically unable to make decisions for yourself. coupled with a living will in which you spell out specific wishes regarding medical treatment in any number of scenarios, your wishes have a good chance of being respected. seems like you cover all bases here without giving up legal rights such as you described above in your mother's situation. am i wrong?
just minutes prior to my stroke (which was caused by earlier aneurysms that ruptured as a baby) i had been a responsible competent adult. i managed the family finances, ran a large house, kept my husband and eleven animals healthy and well fed, worked 3 12's per week as a psych nurse and fill-in supervisor,
sat on several committees and advisory boards, volunteered with several organizations, was active in our church and ... wham! suddenly, everyone was talking over my head as though i weren't there and had no opinion about my health outcome. as though i had been the dog at the vet...
that was the correct answer for me then and now because i was and am at loathe to relinquish any of my personal decision making power. my health poa clearly states my wishes and i know, beyond a shadow of any doubt, that my husband will carry them out as written down, as i will undoubtedly predecease him.
the way our wills are written, we will each automatically inherit what the other partner held at the time
of the union, with a few exceptions, such as personal bequests, and any trusts held by either marriage partner. that's "joint tenants in common" in my state, and the trusts part is an add-on.
my mother did indeed have a durable poa, which i did not want -- at least not right then. i had the stroke the day after my 54th birthday. that's young! i don't think my generation of baby boomers thinks of its collective self as "old" now, any more than we were like our elders when we were in college
or in the decade after. i think that attitude will come back to bite many of us in our collective butt as we age, just as many of us didn't think realistically about saving for retirement. health care, health poa, durable poa, limited poa, aif, savings, ira... all part of the same great big package.
Exactly as Skyler says - DNR is simply if they were to be found unresponsive and having MI you wouldnt be jumping up and down on their chest. In the UK we used to have 'NFE' which meant not for escalation- but it then becomes a grey area and most Drs I would guess would want to be seen to be actively doing 'something' - however if the pt is palliative then appropriate care plans (not sure if you guys use Liverpool care pathway) should be in situ.
my mother did indeed have a durable poa, which i did not want -- at least not right then. i had the stroke the day after my 54th birthday. that's young! i don't think my generation of baby boomers thinks of its collective self as "old" now, any more than we were like our elders when we were in college
or in the decade after. i think that attitude will come back to bite many of us in our collective butt as we age, just as many of us didn't think realistically about saving for retirement. health care, health poa, durable poa, limited poa, aif, savings, ira... all part of the same great big package.
yes, too young to have a stroke. my mother had her first at 48 and has had many subsequent, some "small," some very "big." as i approached my 40's i became all too aware of my own mortality. when we found out we were expecting our first child, i discussed many end of life issues with my husband, got a dpoa and living will. it occurs to me that i was not a nurse at the time and need to go back over the living will and address potential situations that i have feelings about as a result of things i have witnessed over the years of being a nurse. the more specific i can be about what i want done or not done, the less of a burden making those decisions would be for my husband and other loved ones. and i think you are right about the baby boomers. that's a scary thought. i don't think my 52 y/o brother has saved a dime for retirement and i'm worried my other brother hasn't saved much. oy...
I've heard that a million times. I think the best response is something along the lines of - a DNR means that we should not resuscitate the patient if they die. It does not mean that we should allow the patient to die without attempting to treat them. I guess sometimes people need a reminder. Perhaps a quicker answer would be - The patient is not dead yet!
There is no reason a patient with a DNR should not be in the ICU either - unless the only thing they do in ICU is code patients - yet I have heard that many times when patients get sent to higher level care from med/surg. Now hospice or comfort measures care is another story. I think sometimes people confuse a DNR order with comfort measures level care.
Some patient might have more detailed documents explaining that they do not want life saving measures like IV fluids, aggressive treatment - things like that - but that is not assumed just because they have a DNR.
I have a friend in her 30s who is a nurse and would have a DNR due to religious beliefs if she believed there was any chance in it's being honored in a person her age and state of health. She believes that when God decides it's her time to go - it's her time to go. That does not mean that if she is real sick for some reason she doesn't want her illness to be treated!
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Roy Fokker, BSN, RN
1 Article; 2,011 Posts
DNR means "Do Not Resucitate".
True.
But does it also mean that that 98 year old, with severe dementia, diabetes, heart failure, atrial fibrillation, acute/chronic renal failure who now presents because of "fall" and "hip fracture" (broke that hip the third time) - be "treated"? The full works including surgery (assuming Cardiology and Internal Medicine clear him) ??
- Roy