DNR orders

Nurses Education

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After having once again witnessed a doctor ask a patient (this time a 91 YO) "if your heart stopped would you want us to do anything?" and then write orders for a full code without any further explanation to the pt of what this would entail, I have to ask what others do in this situation. Do you confront the doctor? (which I did and got no where with), or do you talk to the pt and actually explain what a code is? (I didn't this time since it wasn't my patient and he wasn't critically ill-but that still wasn't the point).

Specializes in ICU.
Kardex indicates DNR or AD, reported by off going shift that pt is a DNR or has AD, but there is a 50/50 chance that this is actually addressed on the chart. I have to address the issue with a patient almost every shift- and the answer is frequently: "I have been here before- they have it on file". Working agency, different hospitals, yet oddly, this is a common response.

Where is this file?

The other answer is always: "it's at home- do you need a copy?"

grrrr Don't you just hate that?? Some patients/people just don't realize that those papers are absolutely no good at home.

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Specializes in Oncology, Triage, Tele, Med-Surg.

"At home" is at least better than "In the safe deposit box."

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grrrr Don't you just hate that?? Some patients/people just don't realize that those papers are absolutely no good at home.

So you don't know where "the file" is either?

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There was a 67 year old pt on my ward with a history of CHF, multiple MIs, a CVA, a hx of brain ca, lung ca and was currently being treated for mets in his face and still no DNR!

And the other day I had to go into a room with a doctor while he told a pt with intellectual disabilities and her family that the lesion they had removed from the pts brain was a met from a breast cancer. THe family were quite clearly devastated and had taken this to mean it was terminal - I explained to them later that the doctor hadn't mentioned the word "terminal" and there were plenty of options at this time and they needed to wait on further histology and tests before they should start discussing funerals and what not. Then in the notes I saw the doctor had written "informed pt and family of diganosies, family understood and were happy with my explanation". Well, from spending 30 minutes in an office with the mother of the pt, listening to her sob and go on about how to bridge the subject of what the pt wanted done (funeral wise) it was clear the family did not understand!

And it was the first time I've ever had that issue given I'm a new grad! The doctor had more years under his belt of practice and I had a few months!

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What about a family in denial who refuses a DNR? I had a 104 year old end stage Alzheimer's pt who was sick with it for 30 years and the family wanted the works on him. He had no quality of life and they forced him to stay alive in that wasted body because they believed he'd snap out of it and get well.

I felt his sternum and ribs disintegrate when we coded him for the last time.

He died on Christmas day. This recent Christmas. The family showed up with presents because we called with the news after they'd already left the house. So they were screaming in the halls, devastated.

It was charted that they'd had DNR explained to them, and they wanted us to go after this guy with all guns blazing if his heart stopped.

Am I horrible if I say I feel no sympathy for this family, but my heart goes right out to that poor old man who was kept alive and miserable for so long? Who wants to spend the end of their lives like that?

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Specializes in ICU.
What about a family in denial who refuses a DNR? I had a 104 year old end stage Alzheimer's pt who was sick with it for 30 years and the family wanted the works on him. He had no quality of life and they forced him to stay alive in that wasted body because they believed he'd snap out of it and get well.

I felt his sternum and ribs disintegrate when we coded him for the last time.

He died on Christmas day. This recent Christmas. The family showed up with presents because we called with the news after they'd already left the house. So they were screaming in the halls, devastated.

It was charted that they'd had DNR explained to them, and they wanted us to go after this guy with all guns blazing if his heart stopped.

Am I horrible if I say I feel no sympathy for this family, but my heart goes right out to that poor old man who was kept alive and miserable for so long? Who wants to spend the end of their lives like that?

It never ceases to amaze me when something like this happens. I work LTAC ICU,, where I see my more than my share of these dramatic outbursts. I've seen grown men and women throw themselves on the floor in an epileptic FIT when their 92 yr old grandparent died after being a nsg home pt for more than 10 years, contracted, drooling and out of it for YEARS... It is something that I can honestly say that the whole family has psychotic issues. Dellusions, falling just short of an active psychosis. I've studied these people for years and can't get my mind wrapped around where these false hopes come from. I certainly have made a point not to come close to giving any.

I know that typically, a family will accept that their loved one is aging and is ready to die when they're past 75-80 yrs old. BUT, that occassional family who is like what you described here... their loved one past 90, 95 and even 100..... Those poor old grandma's and grandpa's who have lived a wonderful life, it only takes one or two compressions to break their sternum and ribs. I think that (absent a REAL psychotic diagnosis) the family would understand better if they REALLY knew what happened to the patient's body when we started giving Levophed or did compressions.. or if they really knew how it felt to be intubated. The family only sees the patient once they've been cleaned up, looking their best possible. They don't stay in there to see the look on the pt's face when they're intubated, contracted, with bed sores, as you rip off the tape from their butt and wash their stage 4 sacral decubs and insist on repositioning them Q2 hours, while you're telling them you're sorry but you must do this, so they will "get better".. yeah right, okay... The family is full of delusions and false hopes.

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I personally think it's selfish. In the 104 year old man's case he probably died ages ago mentally. He was just a shell of a man. When I looked into his green eyes, they never looked back, and he wasn't suffering any kind of blindness. There was no person left.

I cry about that poor patient. I hope nobody ever does that to ME...

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Usually we very politely and respectfully appologize to the patient, explaining that it was an error.

Then we . . . you know . . . kill them.

:D

[j/k]

OK... so now you have appologized to me... are you also gonna explain to me just how you are going to kill me? Just how are you going to do it?

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When I'm that old and my ribs are brittle enough to snap or if I have a terminal ilness, I would like to be a DNR. The unfortunate thing is, there are medical professionals that think it means "do not treat".

There is also the flip side, where sometimes the Dr. will overrule the DNR for whatever reason, even if it is against the pts. best interest. And they suffer for it, because the Dr. just can't let go.

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I just had dinner with a cardiolgist friend of mine who told me the survival rate for MIs in emerg is about 10% and even less after they've been on the floor awhile. I just ran a code tonight on a 99 yr old woman with CHF. What do you think happened?????? I don't get it??????? MRPs need to be more forthcoming in explanations of care and care expectaions, especially with the sevre senior crowd. Not like the don't deserve the chance. But throwing a 99 yr old on the floor and cracking their ribs for CPR to lose them within 12 hrs.........lets think about dignity and quality. Im sure the family wouldnt have wanted it if they new the truth

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Specializes in med/surg/ortho/school/tele/office.

When I get a patient, I always discuss code status. It is very easy to bring up especially upon admission when you screen for advance directives. I then inquire exactly how much resuscitation they want and explain what CPR REALLY is, not what you see on TV. Most people don't realize how much damage CPR does especially to an elderly person who we are resuscitating to prolong the inevitable. If I have a patient who is going downhill I will broach the subject with the family. Yes, it is difficult and uncomfortable and often times the doctors wont bring it up. If you think about it a lot of MD's don't want to ever give up. They are taught to treat and conquer it goes against their training. Many times when it is brought up and the patient/family has a real understanding of what happens during a code they don't want it done. I have had elderly people tell me "hell no, don't do that to me." I'm talking about very elderly patients, or those that are terminally ill on their last legs. I have no problem running a code when it is appropriate. I don't want to sound like I am inhumane, but really coding a 98 year old is cruel. I have had doc's come up during a code and take a look at patients who have no chance and say "you have got to be kidding me, why are we doing this?" Why, because the doctors don't do their jobs to begin with. Yes people do have the right to be coded when they are 98 if they have been informed and this is what they desire, but often times it is really not what they or their family would want.:banghead::banghead:

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OK... so now you have appologized to me... are you also gonna explain to me just how you are going to kill me? Just how are you going to do it?

It'll most likely be a complication of the humor transplant you so desperately needed.

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