DNR

jbresolin · Oct 14, 1999

Ahn- I found a patient in a geri-chair in the hallway with a tube feeding pulled up int her nose and noisy lungs. She had aspirated feeding. I got help to get her back to bed and suctioned her airway. She continued in respiratory distress and I called her doctor. The patient was a no code blue patient. I did not call a code and the doctor was upset when she arrived because the patient was getting worse. We eventually did code her and I asked why. The physician explained that because she had aspirated the tube feeding we should try to correct that. The patient was elderly with multiple problems and a poor prognosis. There is probably some liability for nosocomial problems regardless of code status.

Ahn · Oct 14, 1999

Sounds alot like my situation. At least you got some feedback from the MD to clarify why this situation was not a "resuscitation," but a correction of an emergent situation.

Thanx!

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Keeping the Faith

Joybelle517 · Apr 3, 2006

So if they stop breathing, or need suctioning to breathe, does that mean that you would not suction them?
CPR - Cardio Pulmonary Resusitation.
As long as you are not "bouncing" on their chest in an effort to re-start their heart, would you consider that "artificial" resusitation?
Devil's Advocate [And I'm not being stupid], if the pt choked on something, and only needed their airway cleared, would that be a violation of a DNR?

I know this thread is quite old, but I found it while searching this topic on the internet, and this situation almost applies to what the nurses at my job are facing now.

We had a resident at the nursing home in Wisconsin I work at die at the breakfast table about a month ago. She was being fed oatmeal when she suddenly dropped her head, wasn't breathing, non-responsive, and was bluish.

The RN on duty called me and another nurse to her room where we immediately started assessing the situation. She was a DNR, but we had to make sure she wasn't choking.

I had a pulse, but she wasn't responding and not breathing. The RN put a glove on and did finger sweeps while the other nurse went to get a suction machine. Nothing was brought out of her mouth but some phlegm and bits of oatmeal.

While the suction machine was being set up, I lost her pulse. She was sitting in her WC during this entire time. We suctioned her, but didn't bring up anything more than what the finger sweep got.

We got her into her bed, where we took a BP and apical pulse. Nothing. So it was a done deal.

We called the family and the coroner ruled her death the result of CHF. Just another day at the nursing home, right?

Well, it just so happens that the housekeeper who was present that day in the DR reported to the granddaughter, who is her best friend, that 'Grandma' didn't die from CHF, but that she was choking, and we stood around watching and did nothing to help her.

The state was called in to investigate and they put our facility into an 'immediate jeopardy' status. Their beef was that we didn't attempt the Heimlech manuever in an effort to clear her airway, if it was in fact blocked.

When I was interviewed by the state rep, she asked me why I didn't perform the Heimlech. I told her that I felt it was better to perform manuevers that would get her breathing again, if she was choking, and since the CNA stated that she'd had nothing but oatmeal, it was fruitless to do the Heimlech.

We have been fined big time, but without an autopsy, they cannot prove she died from choking, however, this is now the dilemma....

If a resident has a DNR order, when do we draw the line? For instance, if she had been choking and her heart stopped as a result, do we initiate CPR because she didn't die from natural causes? What if she'd been eating in her room, and when the tray is picked up, she's discovered not breathing and no heartbeat. Even if she had been choking, do we initiate CPR? And what about the liability of doing so?

The DON is getting policies on the 'what if's' this week, but have any of you ever been in this situation or have any idea what the laws on these scenarios really are?

I was doing a search on the web to find this kind of info out, but couldn't find anything useful but this forum.

Thanks.

SuesquatchRN, BSN, RN · Apr 3, 2006

Another nurse working on a separate floor began to be very vocal, and very critical of my decision to "resuscitate" a DNR, which divided the staff.

"DNR" is quite different than "Kill with Incompetent Care," no? How could it be interpreted to mean, "Let's choke her to death."

Oy.

TazziRN, RN · Apr 3, 2006

I have not read the other replies. "Do Not Rescucitate" does not mean "Do Not Treat." It means that if the heart or respiratory drive should fail, you do not use artificial means to try and bring it back. Up until that point, however, you treat your pt as vigorously as you would anyone else.

Joybelle517 · Apr 3, 2006

I have not read the other replies. "Do Not Rescucitate" does not mean "Do Not Treat." It means that if the heart or respiratory drive should fail, you do not use artificial means to try and bring it back. Up until that point, however, you treat your pt as vigorously as you would anyone else.

Perhaps I should start my own thread asking my questions.

CoffeeRTC, BSN, RN · Apr 3, 2006

This may have seemed like a frivolous exercise, but in my experience as an agency nurse, I have been told everything from withholding CPR to withholding suctioning, insulin, and enteral feeding when they had already had a PEG tube placed. It is very frustrating to walk into a situation where a swift, rational decision needs to be made, and that decision is misinterpreted as challenging an institution's standard of practice.
In one particular situation, I was working as a RN Shift Supervisor. A resident with a PEG tube, in a semi-vegetative state began to aspirate feeding solution, secondary to not having the head of the bed elevated after being turned by the NA's on care rounds. When I found this resident, she was ashen, gasping, and struggling for breath. I suctioned her aggressively, and supplemented oxygen by bagging her for two to three breaths. She began to breathe on her own, and a nasal cannula was applied with oxygen until her color returned to normal.
Another nurse working on a separate floor began to be very vocal, and very critical of my decision to "resuscitate" a DNR, which divided the staff. The Nursing Director of the institution did not criticize my performance. But as a result of the incident, I have elected not to return to this particular institution, as their policy was unclear, and this had not been the first time that as a nursing supervisor, my interpretation of an ambiguous policy was neither exonerated nor corrected.
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Keeping the Faith

What you described is okay for a DNR status. You were providing appropriate care. The person who left the bed down put the pt at risk for the aspiration.

Sooo here is the scene. Pt is DNR, awake, alert and in the dinning room eating lunch. (hamburger, etc) Begins to cough, does the universal sigh for choking, turning blue. What do you do? Heimlich. Okay...its sucessfull, but now the pt isn't breathing...now what? Rescue breathing? Now no pulse? Now what? Remember the no cpr status:uhoh21:

HappyNurse2005, RN · Apr 4, 2006

We have hte DNR with 2 sections. FIrst is "pt will receive NO resuscitative care....." la la la.

next is the section where it says "pt is not to receive" and then you check by what they don't want.

often we see a "partial DNR"-no intubation, no compressions or something of the sort. Some of the eldery will want meds, bagging, but nothing traumatic like compressions/intubation/shock.

Had one lady, who's code was dnr-one shock only. No meds/airway/nothing. Just one shock. If that doesn't work, then tough toodley.