DNR status and therapeutic hypothermia

[MunoRN, RN]

I'm wondering what people's thoughts are on using DNR status as a contraindication to therapeutic hypothermia (TH). There's broad disagreement at my facility which produces inconsistent care, and often just delays the initiation of TH for many hours (ER doc doesn't initiate it because it turns out the patient is DNR, then the intensivist does).

Obviously a DNR patient in cardiac arrest shouldn't be resuscitated, once you've progessed to post-resuscitation care it would seem that ship has already sailed.

The argument for still providing TH to DNR patients is that while it may (or may not) improve survival, it also may (or may not) improve neurologic functioning in the event of survival. It's hard to believe that the majority of people who chose to be DNR would rather survive with poor neurological functioning that to survive with improved functioning.

[emtb2rn, BSN, RN, EMT-B]

We've had instances where the dnr status was discovered after rosc, the family requested meds d/c'd & terminal extubation which was done. In each case, the pt bradyed down into asystole & died fairly quickly.

[MunoRN, RN]

We've had instances where the dnr status was discovered after rosc, the family requested meds d/c'd & terminal extubation which was done. In each case, the pt bradyed down into asystole & died fairly quickly.

That's more of a transition to comfort care than it is a transition to DNR status since they are two very different things. The argument is that we should stop TH once we find out the patient is DNR even if the patient is going to remain intubated, or if we're going to extubate due to the DNR status, the problem is that most patients who qualify for TH aren't actually vent dependent, so they still survive just with less chance of a good neurologic recovery.

[CodeteamB]

I agree, if we have circulation post arrest, let's do what we can at that point to promote higher function. Especially with TH, which is minimally invasive and easy to initiate.

[Esme12, ASN, BSN, RN]

I agree once the ship has sailed and the family doesn't want to terminal wean....give them the standard of care.

[SwansonRN]

I don't really understand. TH for post ROSC for someone who is DNR? Were they made DNR after they were resuscitated? Or were they found down and resuscitated in the field before their code status was discovered in the hospital? Either way I don't think it should be a contraindication, but I would definitely think we should be careful and make sure we aren't going against what the patient would have wanted.

[MunoRN, RN]

The challenge is that DNR is listed as a contraindication in almost every source on TH available, although it's good to see it's not just me that disagrees.

[MunoRN, RN]

I don't really understand. TH for post ROSC for someone who is DNR? Were they made DNR after they were resuscitated? Or were they found down and resuscitated in the field before their code status was discovered in the hospital? Either way I don't think it should be a contraindication, but I would definitely think we should be careful and make sure we aren't going against what the patient would have wanted.

It's usually that a patient had a documented out of hospital DNR that responders weren't aware of, they had expressed DNR wishes to a POA, or family POA make a patient DNR prior to initiation or prior to finishing TH.

[calivianya, BSN, RN]

I think it really depends on what type of DNR we're talking about. There are lots of variations of DNR - I have had a lot of patients lately who have wanted everything done except compressions, up to and including intubation, dialysis, vasoactive medications, etc. There's a big difference between that and someone who has checked comfort care only and who has not consented to intubation and IV meds/fluids of any kind. I'd say that if a patient is DNR and comfort care only, it's a little harder to justify doing because it's common practice to give the patient paralytics, place him/her on the ventilator if not already intubated, and give IV meds as needed, which might go against the DNR order. If a patient is DNR but wants everything to be done except compressions, it would be pretty horrible to not initiate therapeutic hypothermia.

[HouTx, BSN, MSN, EdD]

Whew! This is a matter for your Ethics Committee... that's why they exist.

[1fastRN]

Interesting point.

I once had a 98 y old DNR/DNI who came in circling the drain and our ER doc decided to put her on bi-pap. I felt bed for her as she fought the bipap... can't be comfortable having a vacuum on her face.

Regardless, she was discharged back to the NH in 2 days good as new! So ended up being a good thing and no just prolonging the inevitable.

[That Guy, BSN, RN, EMT-B]

If it was me, and you didnt discover my DNR until after you got me back and you have TH going, stop it please. I didnt want to be coded in the first place. I dont care how minimal invasive it is, pull the tube, stop the meds, stop the fluids let me go please