DNR Turning Into Do Not Treat?

Sour Lemon · Nov 24, 2017

Does anyone ever feel like they encounter providers who approach DNRs in a way that basically turns them into a 'do not treat' scenario? I've had this issue several times lately where patients who were DNR, but not comfort measures or hospice, were experiencing something and were symptomatic, and when I called for orders the response I got was "oh that patient is a DNR" with no orders received. For example, I had a woman who was a DNR who had a blood pressure of 60/40 the other night and the hospitalist did not want to treat it, stating that she was a DNR. Or another instance recently where a DNR patient who was due to be discharged to rehab the next day aspirated, was in acute respiratory distress, and needed to be intubated, but when I called I was met with the "DNR" response from the doc. It frustrates the heck out of me. I've always approached the concept of DNR as a 'we do everything up until the moment the heart stops' unless of course there is a 'do not intubate' or a comfort measures/hospice order.
I'm trying to brainstorm ways to approach this issue that will get nursing and medical providers on the same page. How do your hospitals do it? Do any of you feel like you have this same issue?

Personally, I get more worked up when people aren't allowed to die naturally. I guess what would matter to me would be the cause of the low blood pressure. If it's part of some natural process, I'm alright with it. The the patient dropped a shard of glass on a major artery, less so.

MunoRN, RN · Nov 24, 2017

Part of the confusion comes from differing definitions, there is a hospital system that defines "DNR" as comfort measures only, for instance. There are many physicians who view pressors as resuscitative and I get where they are coming from, but that really should be based on the patient's pre-arrest wishes.

Generally though, you're correct that DNR only refers to what should be done, or not done, in the event of cardiopulmonary arrest. Sometimes it has been established that the patient would not want ICU level care, and the physician will sometimes refer to this pre-arrest directive as a "DNR", so even though they are using the wrong term they are still correctly acting on the patient's declared wishes. There are also times where more aggressive care isn't appropriate for the patient, whether or not the patient wants more aggressive care, and the MD will sometimes (incorrectly) refer to this determination of medical futility as "DNR".

oceangirl1234 · Nov 24, 2017

Had a resident say, "patient is a DNR so it doesn't matter if he dies." Meanwhile patient is crying and can't breathe because he is filled with fluid. Was horrifying.

WestCoastSunRN, MSN, CNS · Nov 24, 2017

DNRs are not one-size-fits-all. What everyone needs to be on the same page about it what each individual patient's DNR means to/for him/her. If a patient does not wish to be intubated under any circumstance, then aspiration pneumonia still will not qualify to intubate.

I have had patients who were being treated aggressively from a medical perspective who, also, were DNRs. As the patient advocate, it's my job to know the intent behind the DNR and the details of what we will or will not do. That may involve (and often does) having frank discussions with providers and family about the treatment plan. I don't think there is a magic formula for making it happen, but I do think it requires directness.

I will sometimes frame these types of discussions (where nursing and medicine are not seeing eye to eye) in terms of, "help me understand, why are we ..." or "ok.... can you explain how that falls in line with the patient's wishes? My understanding is.... " or "this is a really difficult case, do you think we could use an ethics consult?".

Typically, IME, we think about the ethics consult too late -- the whole hindsight is 20/20 type thing -- after we've done (and now realize we've done) way more than we probably should have.

peripateticRN, BSN, RN · Nov 25, 2017

Where I am in Canada we have Goals of Care designations instead of simple DNR orders.

There are 3 main categories: Resuscitative, Medical Care and Comfort care and sub categories in each (sounds complicated but isn't actually).

For example if you are an R1 - which is the automatic designation unless otherwise stated - all efforts will be taken including compressions, intubation, ICU admit etc... if someone is an R2 they have decided they do not want compressions but intubation is okay, R3's may have life support without compressions or Intubation - they also will not typically have an ICU admission.

We will only call a code for R1/R2s.

The next category is Medical care - there are 2 categories here - basically with varying levels of medical support. they will still be treated for their ailments with the exception of resuscitative measures - This is the level of care most of our geriatric patients fall under.

Finally we have 'Comfort care' - Generally people with a C1/2/3 designations are in varying levels of palliation and all interventions are based on comfort measures.

This system seems to work really well for us - patients always have the ability/right to move up or down levels as they and the treating team see fit and it takes away much of the ambiguity that I understand are an issue with DNRs.

Im sure I didn't explain that fantastically... but that's the jist of it anyway...

cleback · Nov 25, 2017

Yes.... had a patient with bp 70/40, non-responsive....the person had been talking and a bp of 130/80s at the beginning of the shift. The on-call ordered a fluid bolus, and when that didn't work, just stated "oh well, he's a dnr. Nothing more we can do."

I feel like if we don't address this attitude that dnr will carry the fear that organ donation arouses in some. The Canadian system sounds interesting. I'd like to know more about how other countries address this issue.

mmc51264, BSN, MSN, RN · Nov 25, 2017

sometimes we try to ride the line. If someone aspirates, we will call resp and have them suction a little deeper that we can. Deep suctioning is technically not allowed for DNAR but ...

I worked at LTC rehab and they had so many permutations of what they wanted or didn't want done, it was so confusing. Where I am now it is DNAR "do not attempt resuscitation" so basically all or nothing. There is some common sense used though.

KelRN215, BSN, RN · Nov 26, 2017

I feel like it's the opposite in pediatrics. But when a child is a DNR, it's generally because they have a progressive disease and are expected to die in the relative short-term, not just someone who's lived their life and doesn't want to be resuscitated.

I will say our Resuscitation Status orders are very specific though. We had a long term patient when I worked in the hospital who was an adult but had been ill since she was a child so was still treated at the pediatric hospital. Her DNR order was no compressions, no cardioversion but intubate if parents were not present at the time until they could come in and make a decision.

Our orders usually specify whether or not to: bag, deep suction, intubate, perform compressions, give arrest medications, provide electrical cardioversion, insert chest tubes and maybe some other things I'm forgetting.

I find that people have a really hard time with what comfort measures only means in pediatrics. When I worked inpatient, I took care of an 8 year old when he became CMO and the medical team was still ordering daily labs, q 4hr VS and all kinds of other things that weren't for the child's comfort until our CNS said "enough."

allnurses Guide · Nov 26, 2017

DNRF mean different things to different people which is why several states adopted the P.O.L.S.T (Physicians orders for life sustain treatment) system. This is a clear form filled out with the patients or patients family that goes over the patients wishes on what they would want done in the vent of an emergency. I will post a copy of the form that is filled out here as well.

When my mother was in mid stage dementia she was taken to the hospital with a suspected GI bleed. The ER physician did not want to do a colonoscopy because she was a DNR. We pulled out her POLST and clarified that she did want trial measures but no extraordinary measures taken.

http://capolst.org/wp-content/uploads/2017/09/POLST_2017_Final.pdf

POLST documents clearly state if the patient wished to be intubated and under what circumstances and for how long. There are other parameters as well.

Hppy

chtzu, BSN, RN · Nov 26, 2017

I remember wanting to get an ABG on a patient who was really short of breath and when I managed to get the stat order from the hospitalist, I call the respiratory tech to make them aware and he literally yelled at me "well, isn't the patient dnr/dni?!" I was so bothered by it. Just because they're a DNR doesnt mean you don't help relieve their s/s.

Tomascz, ASN, RN · Nov 26, 2017

Had a resident say, "patient is a DNR so it doesn't matter if he dies." Meanwhile patient is crying and can't breathe because he is filled with fluid. Was horrifying.

Any DNR can be rescinded by any patient at any time. In any case, O2 and Morphine would be the least you could do for this person.