DNR orders

[Erin]

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).

[mappers]

Since this is about education, I need it. I've been a nurse on a Med Surg floor for about 16 months. I've never seen a code. We RR patients and move them to ICU before they get to the point of coding. My floor also does oncology and we often get the pallitive patients. No codes for them either.

So explain to me what a code entails the way you'd explain it to a patient. How is it different than what you see on ER or Grey's? I'd love to educate my patients on that, but I don't know. They didn't teach that in nursing school.

[HollyHobby]

I explain what a full code means in detail. First, there are chest compressions. If the patient in question is elderly, I emphasize that doing chest compressions will almost certainly cause the ribs to be broken. Then there is intubation; I explain that a tube will be shoved down the patient's throat into the lungs so we can breathe for them. Then, there are medications that we can give, which may or may not help to keep the dying heart beating. Then, sometimes, we are able to shock the patient's heart to get it to beat more normally.

I'm honest about the patient's chances of surviving such a thing. In most cases, (most patients who are at the end of life are quite elderly and have several comorbidities) doing a full code will allow the patient a few minutes or a few hours, possibly (in the best case scenario, although the patient will almost certainly be brain dead) a few days before death occurs.

Of course I tailor my explanations to the particular patient. A very few people may only need a few defibrillations before we're able to get things under control, and that person may go on to live some more life. Most of the time, however, a full code is a futile attempt. It is (in my opinion) degrading to the person's body. The family is unable to hold that loved one's hand while life gently slips away. Instead, death is a fiasco and a torment.

It depends on the patient, the patient's situation, and the patient's wishes. Too ofen, the patient's wishes are irrelevant: the family wants us do to EVERYTHING! I respect that. They don't know. So I do it. If grandma is 99 years old and full of cancer, but the family wants everything done even after I've described in detail what "everything" means, so be it. My one consolation is that by that point, grandma is too far gone to feel her ribs shatter.

I also often have patients who believe that we want them to die so we can give their organs to other people. I try to explain that we wish no such thing, we don't have any incentive to give your organs away, but they've seen enough movies or read enough books to believe that this is what healthcare is all about. Fine. You're a full code.

When an end of life situation occurs, it so often means the patient's wishes don't matter. Most people do not communicate with their family what they do or do not want done. So it's up to the family, who almost invariably choose to have everything possible done to "save" their loved one. I do not have a magic wand, but if they tell me to break their grandma's ribs, by god, I break their grandma's ribs. This used to torment me to no end, but I've come to peace with it. By then, grandma isn't feeling the torture anyway.

Denial is stronger than love.

[divaRN*]

I wish we could show patients and families a video of a real code so they could see what really happens. Sometimes explaining it still doesnt sink it. We do not use DNR bracelets where i work but i think we should. I can not tell you how many times myself or another nurse has walked into a room to find a pt either dead or very close to it. If this is not your patient you do not know their code status without looking at their chart. A bracelet would make it a lot easier to know how to initially respond to the situation.

[imintrouble, BSN, RN]

I wonder what the family would say if they could feel a rib crack, or witness the pain everytime the ventilator inflated that lung.

Makes me cringe everytime I think of it.

Absolutely an informational video should be part of a signed DNR.

[mskate]

I firmly believe that every.single.hospital should have an MD, an RN with ICU experience who has worked with the really bad "do everything" population, and a social worker to sit down with patients early on in the admission to talk about code status, palliative care, pain management and *realistic* options.

Nurses who have 6 other patients with each admission, and docs who are running around with their patient load don't usually have the time to sit down and spend the 30 minutes, an hour, or so to really explain things, learn about patients and their fears, etc...

I think it would be a fantastic program to have in every hospital.

[Kim5/08]

I am again so greatful for my job and most of my colleagues after reading some of these posts. When code status is addressed, we have three levels of DNR. In explaining these, I think it helps so the patient/family understands the DNR doesn't mean do nothing/do not treat. We use DNR bands and the POLST is the first page under physician orders.

For those physicians who do not address code status, I will make this statement when I round with the physician "Dr. X, we need to address code status." That simple. No beating around the bush. I've yet had a physician complain or "report" me. What could they really say? "She made me talk to my patient about their wishes?"