DNR vs withdrawal of treatment

[acquiesce1908]

I really am bothered by a situation that I encountered at work the other day. I seek an honest opinion from whomever wishes to comment. Here was my situation that occurred...

I work on a Surgical Heart unit. There was a pt that had been on our unit for over a week that had Open Heart surgery. The pt indeed was realy sick and thus death was eminent. On this particular day I worked, the patient's family had made the patient a DNR. The patient was on about seven different gtts which about 3-4 were inotropes and pressors. When I received report from the previous nurse, the nurse informed me of the DNR order that was recieved today. At the time of report the pt.'s BP was 80/40 (58), so naturally I wanted to increase one of the patient's gtts. I was told that when a patient is a DNR, that gtts are no longer titrated. Now the DNR order reads as follows: DO Not call a code blue, No CPR, No ventilation, and No initiation of new medications or change in current medications for RESUSCIATIVE efforts. Now, if I were to increase the pt's gtts, would that have conflicted that DNR order? Was increasing a gtt classified as a "resusciative effort"?

O.K. so that was one issue. The next was that the nurse that gave me report told me that the cardiac surgeon had told the nurse that when the patient's gtts ran out, to hang "pretty bags" (plain IV fluids). Now this was a major problem for me, I could not believe that someone would say something like that. Now remember that I told you all that this patient's death was eminent, but I do not wish to rush anyone's process of death.

Oh, but this is not the end of my day.....

The patient's BP dropped to 50/30 (45) so natuarlly I called the family and the chaplain to come in to be with the patient. I spoke to the same cardiac surgeon shortly after and just give a quick update. After telling the surgeon the BP, the surgeon says to me " Well you can just shut off the Levophed. 50/30 is not really a blood pressure. I mean it depends on how you feel morally".:angryfire Once again I could not believe that someone would put me in a situation like this. Needless to say, I made sure that the patient remained comfortable. I gave the family time to sit with the patient and so forth. After the family had been there for most of my 12 hour shift bascially waiting for the patient to die, the spouse told me that they were going home and asked me if I thought that the patient would go soon. So I explained to the spouse that part of the reason that the pateint was still here was because of all of the medications and temporary pacemaker and so forth. I went on to expalin that the patient is a DNR (that only if the patient were to arrest we would not do anything) that treatment (medications, etc.) was never withdrawn. The spouse immediately told me "Oh, no I do not want any of those things anymore, {the patient} has gone through too much already".

It was then that I obtained a witnessed consent for the withdrawal of treatment and when the cardiac surgeon made rounds shortly after, orders were written to stop the medications and to disconnect the temp. pacemaker. The patient died shortly after the pacemaker was disconnected.

I apologize for this being so long, but this entire situation has been bothering me since its occurance.

[SouthernLPN2RN, MSN, RN, APRN, NP]

I know this was a rough situation to go through, but I feel that you did the right thing and I can only hope that should I ever be a pt in that situation, I'd have you for my nurse!!! The decision was the family's to make. You allowed them the time to spend with their loved one and kept them informed. IMHO, "pretty bags" are unethical, and probably illegal, so I'd be quite upset with an order to do that myself. About the gtts, I don't feel as if that was a resuscitative measure. Prolonging life, yes, but they were in place when the DNR was signed, so it wasn't anything new.

[suzanne4, RN]

It is hard to go thru, and unfortunately comes with working in a hospital setting. In answer to your questions, to go up on the drips would be against what the doctor ordered. It stated no change in meds for resusitative requirements, which is what you would be doing if the gtts was increased.

At times gtts can be titrated if there is just a DNR order........but when you have specifics written, not to make changes, at least titrate up, then you have to follow that as well.

DNR can mean NO CPR, NO Defibrillation, etc. Other items need to be specified and they were.

[AlexCCRN]

You have it all right. DNR does not equal WOT orders. And euphamisms that were mentioned are innapropriate of course and unethical. So, you continued to treat the patient as previously written orders prescribed and not until recieving new orders to withdraw treatment did you do so. This is our job, it's what we do without prejudice and frequently in cooperation with coworkers who may not be up to the task. Sorry for you, grateful that the patient and family had the benefit or your presence.

In my last WOT experience, I was hanging Prevacid and antibiotic 10 minutes before turning off the ventilator. Others were saying I was being .... whatever but, I know what my job is and don't pretend otherwise. Advocate right up to the last breath and then keep on advocating.

[hrtprncss]

Hello you're right to get the consent for withdrawal. And you're right to NOT titrate up the medications, even though you wanted to. I work with surgical hearts also and when a patient becomes unstable of course you exhaust everything you can to stabilize the patient. But when the DNR is written, I do not go up anymore. Only down IF AND ONLY IF the patient's bp somehow gets stable enough. Will I turn off the gtt's? Not until the consent of withdrawal of treatment is in the chart.

[medicb70]

Pretty bags??? - Never heard of 'em. Sounds unethical to me. Sounds like you did the right thing. I also have given abx and pepcid up to the last minute. Even done CRRT up to the time of death on a DNR.

I think you might have consulted with the family at the start of your shift to get their feelings about titration of drips and haging new bags. This has worked well for me in the past. Families seem to be very appreciative of any and all information given and allowing them to decide treatment. Of course this has to be discussed with the doctor also, but it avoids issues such as "pretty bags".