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DNR pt with SOB and alert

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by Allend Allend (New) New

Pt was admitted with NSTEMI and large Right sided pneumonia. The pt had a DNR order, Spo2 was 90% on nonrebreathet 15l, pt had 40 of Lasix to no help along with nitro and small dose of morphine for CP. pt was placed on BIPAP tolerated well but dependant on thr BIPAP. My question is since pt is DNR what would be next if BIPAP does not work and he is alert and oriented? I know we still treat but with no intubation?

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

I've seen a fair amount of pts who were DNR but not DNI. So they didn't want compressions/ACLS drugs but were okay with being intubated for a reversible respiratory cause such as pneumonia. That would be something the physician would need to clarify, esp given he is competent to say, "I am struggling to breathe, yes I want help breathing" or "I'm dying and just want to be kept comfortable."

kiszi, RN

Has 9 years experience.

I agree with Here.I.Stand. If the patient's wishes are to not be intubated, then comfort measures would be appropriate. Morphine to ease SOB, anxiety meds if indicated, etc.

WestCoastSunRN, MSN, CNS

Specializes in CVICU, MICU, Burn ICU. Has 25 years experience.

Intubation needs to be discussed. DNR not the same as DNI as PP stated. But you're right.... aside from intubation there's no where else to go (besides tweaking medical management -- which could be a game changer) should he crump further. Is this a COPD-er?

Pt was admitted with NSTEMI and large Right sided pneumonia. The pt had a DNR order, Spo2 was 90% on nonrebreathet 15l, pt had 40 of Lasix to no help along with nitro and small dose of morphine for CP. pt was placed on BIPAP tolerated well but dependant on thr BIPAP. My question is since pt is DNR what would be next if BIPAP does not work and he is alert and oriented? I know we still treat but with no intubation?

It is not that easy .....

There are many things we do not know that influence decision making.

Generally speaking - in patients who do not wish chest compressions or intubations but who agree on bipap usually decide that way because the hope is that the bipap will be only short term until things "get better".

In your scenario, the MD has to have discussions around the goals for care. Considerations are : will the PNA get better and if yes, perhaps the patient can get weaned off - is the pat fluid overloaded? what was the quality of life before? is there a healthcare proxy? is the patient able to verbalize?

Usually, MDs give it some days if they think that there is something that can be reversed like a pneumonia. If it turns out that the patient is DNR and DNI but wishes to remain on some breathing support, it has to be discussed. Some people can get of high flow and wean off from there. Some people decided that they do not wish to go on with breathing support and instead chose comfort measures. Some people decide on intubation although they decided otherwise before and go from there.

Been there,done that, ASN, RN

Has 33 years experience.

Any DNR order should include specific orders regarding intubation.

The patient is alert and oriented, perhaps ask THEM if they want to be tubed?

The patient agreed to DNR status.. BEFORE they needed resuscitation. Now that they need it.. it's a do-over.

Advocate for your patient, instead of that piece of paper.

Appreciate all your comments, I have a better idea. All of these things ran through my head at the time, just needed some input, thank you all.

brillohead, ADN, RN

Specializes in Cardio-Pulmonary; Med-Surg; Private Duty. Has 5 years experience.

My facility has different levels/tiers of code status, not just "full" and "DNR".

First tier is what would be considered "full code" -- compressions, intubation, the whole nine yards.

Second tier is "no compressions" -- intubation is okay, medications are okay, defibrillation is okay, but no compressions.

Third tier is "no compressions, no intubation" -- medications and defibrillation are okay, but nothing else.

Fourth tier is "comfort measures" -- no medications or interventions other than whatever is necessary to make the patient comfortable as they die. We don't even take vitals or put them on telemetry if they're fourth tier.