End of life care - facilitating communication amongst staff

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Does anyone use a worksheet to establish a reference point of what care is to be continued or withdrawn after a patient has been made a DNR and a family meeting has taken place to establish goals of care?

We have made patients DNR and "capped care" and once that "capped care" label is in place certain aspects of patient care become inconsistent. Does anyone use a worksheet of establish care in regards to labs, cxr, abx, etc? I feel like sometimes these patients become like the red-headed step child of the unit and I am looking for a better way to collaborate care.

Does anyone have any experience with this?

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Specializes in ICU.

When a patient is made DNR, we have an order sheet where the MD specifies whether or not pressors are to be given. We aren't withdrawing care, we're just not going to resuscitate.

By "capped care", do you mean comfort care? When death is near, the MD will write orders for comfort care only and d/c labs, x-rays, abx, meds, etc. Otherwise the patient would be transferred to hospice.

Does this make help? It's late and I'm not sure any of what I said makes sense.

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If in doubt, read the protocol for such a case. Ask the charge nurse what the definition is for cap documentation. Alot of liability can be prevented for negligence or malpractice. When nursing care is inconsistent this needs to be brought up to the charge nurse. Remember you are responsible for the DNR patient while they live. I agree with the writer who discussed briefly what DNR means and the use of hospice care. If the treatment is a capitated, then only so much money is available for treatment and care. Different bag of worms than what the writer and I are discussing.

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Specializes in ICU.
If in doubt, read the protocol for such a case. Ask the charge nurse what the definition is for cap documentation. Alot of liability can be prevented for negligence or malpractice. When nursing care is inconsistent this needs to be brought up to the charge nurse. Remember you are responsible for the DNR patient while they live. I agree with the writer who discussed briefly what DNR means and the use of hospice care. If the treatment is a capitated, then only so much money is available for treatment and care. Different bag of worms than what the writer and I are discussing.

I've not experienced capitated care yet. I've only been doing this for a little over 3 years now; have seen one or two charity care cases, so I guess that's the same? In those couple of instances, DNR was never an issue.

Great advice to the OP

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I re-read your note regarding documentation for a patient or medical power of attorney who makes a decision for a NO CODE status (DNR). Inconsistencies in care may depend on the variation of Code Status from patient to patient. The doctor fills out the DNR form for Code or DNR status after an indepth conversation, full disclosure and all while assuring that the patient fully understands what they are agreeing. I have been involved DNR's status in which I had options. They are as follows: Full NO CODE: NO Defib, intubation or meds are to be administered when a patient stops breathing and has no pulse (dead); Partials code status 2. Administer meds, intubate, but no defib. 3. Meds only OR defib only OR intubate only. 4. Defib, intubate but no medications. Nurses must be familiar with each individual's code status.

When a terminal patient is noted to be at the end of life, it is recommended to involve hospice if patient decides to be a full DNR or NO CODE.

Please whatever you do, DO NOT ADMINISTER everything you've got on the crash cart to a patient who died and was a DNR. DO NOT withhold care and everything you have on a crash cart to a terminal or a patient who stops breathing and has no pulse but is a full code. Mistakes happen in Codes Blues mostly by nurses who don't know the orders. Familiarize yourself. You may get in trouble.

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Specializes in ICU.
I re-read your note regarding documentation for a patient or medical power of attorney who makes a decision for a NO CODE status (DNR). Inconsistencies in care may depend on the variation of Code Status from patient to patient. The doctor fills out the DNR form for Code or DNR status after an indepth conversation, full disclosure and all while assuring that the patient fully understands what they are agreeing. I have been involved DNR's status in which I had options. They are as follows: Full NO CODE: NO Defib, intubation or meds are to be administered when a patient stops breathing and has no pulse (dead); Partials code status 2. Administer meds, intubate, but no defib. 3. Meds only OR defib only OR intubate only. 4. Defib, intubate but no medications. Nurses must be familiar with each individual's code status.

When a terminal patient is noted to be at the end of life, it is recommended to involve hospice if patient decides to be a full DNR or NO CODE.

Please whatever you do, DO NOT ADMINISTER everything you've got on the crash cart to a patient who died and was a DNR. DO NOT withhold care and everything you have on a crash cart to a terminal or a patient who stops breathing and has no pulse but is a full code. Mistakes happen in Codes Blues mostly by nurses who don't know the orders. Familiarize yourself. You may get in trouble.

I agree, it's imperative to know the patient's exact code status, which MUST be clarified by the MD in the form of a specific, detailed & signed order. Of course, miscommunication can happen anywhere in the hospital, but I think it becomes more of an issue for floor nurses who have many patients to care for, rather than critical care nurses who have only 2 or 3 patients. I have tremendous respect and sympathy for those floor nurses who have so many patients to care for; perhaps it would help if the charge nurse or nurse manager is also fully aware of the code status for the patients on the floor...I would think this is already the case, but not sure. I know we've had DNR patient's who were coded!

I also think it's VERY important to make sure nurses advocate for those patients who have made their wishes known and want to be a DNR. Get the doc to speak with the patient and get the orders written right away!

I've also seen emotional family members convince an MD to change a patient's DNR status when that patient can't speak for themselves!!! We had to code an end-of-life cancer patient on his 80th birthday because the family decided they couldn't let him die (as he wished) and they convinced the doc to rescind his DNR status!!! Thankfully, for the patient, he did not make it through the 2nd code just 20 minutes later. He got his wish, finally!!

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