Does DNI mean no CPR?

It looks like a question of semantics on the end of your facility. They should probably officially start to differentiate between DNR and DNI. The definition of these terms is set per facility, anyway. At my facility we have DNR, but sometimes DNR can mean to give meds (pressors, inotropes, etc) and has to be specifically documented.

If your facilities definition of DNI is

(Do Not Resuscitate) comfort interventions only. You will not receive cardiopulmonary resuscitation (CPR) treatment with electromechanical devices. A tube will not be placed in your nose or mouth. You will not receive air artificially by either bag or breathing machine.

then at your facility (and those within your facilities care), no CPR gets performed. It's just important to note that while DNI literally means (Do Not Intubate) and DNR literally means (Do Not Resuscitate), the exact definitions are not standardized and are set from facility to facility.

To me, Do Not Intubate means just that. No more, no less. You still do CPR and meds.

DNR is no CPR, no meds, no intubation, nothing. Comfort measures only. O2, treat infections, just no heroics in the event of cardiac arrest or resp arrest.

But surely your facility and your facility's physician has this worked out already. Right?

I really like the new term being debated now AND. Allow natural death, this way you don't get into these kind of semantic issues. In the facility I work at we use BOTH DNR/DNI or each individually. All this revolves around which attending is rotating through our unit too!

Im just uncomfortable with it. If a patient wishes ONLY to not be intubated, but wishes to receive CPR...that isnt an option for the standing orders. I dont like the setup at all. I will discuss this with my manager tomorrow. I just dont feel comfortable with it.

My experience has been the same as vitoandolini, we have pt's who differentiate the DNR/DNI status. DNI means just that, everything except intubation, DNR, no compressions, no intubation, but everything possible/reasonable until that point of resp or cardiac arrest, unless of course they are terminal w/DNR, comfort measures only.

For your own protection, I would get those protocols in writing from my facility. Don't be afraid to have your DON clarify these for you. It's a good question that varies between facilities.

To me, Do Not Intubate means just that. No more, no less. You still do CPR and meds.

DNR is no CPR, no meds, no intubation, nothing. Comfort measures only. O2, treat infections, just no heroics in the event of cardiac arrest or resp arrest.

But surely your facility and your facility's physician has this worked out already. Right?

That is my thinking as well.

Im just uncomfortable with it. If a patient wishes ONLY to not be intubated, but wishes to receive CPR...that isnt an option for the standing orders. I dont like the setup at all. I will discuss this with my manager tomorrow. I just dont feel comfortable with it.

I could see the point in still wanting CPR but not intubation. If it is a patient who has chronic lung issues and knows they wouldn't be able to wean from a vent, I could certainly see that decision.

DNR is no CPR, no meds, no intubation, nothing. Comfort measures only. O2, treat infections, just no heroics in the event of cardiac arrest or resp arrest.

Where I work, there are three levels of DNR orders. DNR #1 means no CPR. DNR #2 means no CPR plus (any or all of) no intubation, no artificial respiration, no IV vasoactive agents, no dysrhythmia treatment protocol, no dialysis, no blood or blood products, no artificial hydration, no artificial nutrition. (Therefore a DNR #1 could be on pressors and a vent but there will be no hands-on CPR). And DNR #3 is comfort measures only.

That is my thinking as well.

I could see the point in still wanting CPR but not intubation. If it is a patient who has chronic lung issues and knows they wouldn't be able to wean from a vent, I could certainly see that decision.

Yea but what a lot of people don't realize (can't believe no one said it yet) but many many times someone needs CPR, they will end up needing to be tubed. I haven't been a nurse for very long, but can only think on a few times when someone needed CPR and didn't need to be intubated (pulseless Vtach that got shocked and converted right away comes to mind).

I guess my point is that the pt and family need to be educated about what happens during a code, so they can make a proper decision. What if you do CPR on the person who doesn't want to be intubated, and you just end up bagging them forever? Do you just stop bagging at some point, or what do you do? Maybe this situation doesn't come up very often, I'm just wondering...

Yea but what a lot of people don't realize (can't believe no one said it yet) but many many times someone needs CPR, they will end up needing to be tubed. I haven't been a nurse for very long, but can only think on a few times when someone needed CPR and didn't need to be intubated (pulseless Vtach that got shocked and converted right away comes to mind).

I guess my point is that the pt and family need to be educated about what happens during a code, so they can make a proper decision. What if you do CPR on the person who doesn't want to be intubated, and you just end up bagging them forever? Do you just stop bagging at some point, or what do you do? Maybe this situation doesn't come up very often, I'm just wondering...

Yes, the doctor will call it, just like he or she would with any code. You won't be doing CPR for long.

Personally, in the vast majority of cases, CPR only isn't going to do much without intubation and/or defibrillation. It often sounds to me that a person or family members figure at least they're trying, and if that fails, then oh well.

There are so many choices of resuscitative measures that it gets confusing. Do not intubate, CPR only, but no vasoactive drugs, no CPR and only vasoactive drugs (shakes head), etc.

There should be two choices: DNR or full code - no variations. Is there something wrong with that?

There are so many choices of resuscitative measures that it gets confusing. Do not intubate, CPR only, but no vasoactive drugs, no CPR and only vasoactive drugs (shakes head), etc.

There should be two choices: DNR or full code - no variations. Is there something wrong with that?

There are, but it really is for the benefit of the patient and for you.

Imagine the patient with a bad heart (whatever the reason) who has been told by his cardiologist that if his heart stops or arrests it aint coming back. With that in mind he asks for no cpr to be performed. However, his bad heart also leads to CHF with occassional fluid overload. It sets on quickly, but a quick intubation, some lasix, and he is back to baseline within 24 hrs. If this is what he wants - who are we to say no? (So he would be no cpr, but ok for intubation)

Now take the person with chronic copd who realizes that once intubated he will remain so forever. He doesn't want to live like that. However, his heart has been "experimenting" with different rhythms lately and the docs are trying to stabilize his medication regime so his heart remains beating in sinus. One day, one of those experimental rhythms occurs at just the wrong time and he goes into V-fib. A quick shock and 2 minutes of cpr put him back into sinus. Should we deny this?

I find confusion really only comes into play when the treatment options and alternatives are not explained well. People don't like talking about death so they gloss over it and lifesaving treatments become "do you want us to pound on your chest or stick a tube down your throat?" -- Well no, not if you put it that way.

Start with what the patient really wants, and then make the treatment surround that. Hope this helps

Pat