End of Life and DNR

bellehill, RN · Sep 19, 2005

Just wondering if it is different from one state to the other for these ones.
1. DNR : does it imply DNI?
2. DNR : does it mean no atropine, no lido? If you give theses, any difference on who it would be such as your dying pt?
3. How is DNR approached in pt and family? Is it talked about on admission, or only if death is pending. Is the nurse or MD approaching the pt's/family regarding DNR?
Thanks!

We have a very different way of dealing with DNR in Ohio. There is a DNR-CC and a DNR-A. THe DNR-CC denotes only comfort care, no treatment with meds, TF, intubation....the DNR-A denotes that we treat everything up to the arrest, so we can push meds but no intubation or compressions/defib. Sometimes the families state the patient is a DNR-A but can be intubated or they will allow one round of defib/compresions which really screws everyone up and requires the nurses to do a lot of teaching for the family members. This is the first state I have worked in with 2 different DNR designations; I still have to look up the policies after 1 year.

papawjohn · Sep 20, 2005

Hey Y'all

The silly business that Bellehill points out just gets me all riled up. The whole ACLS 'code' is a MEDICAL PROCEDURE, doggonnit!!! It's typical of some 'code' orders to say 'give meds but no compressions' or 'ambu-bag but do not intubate'. But if the emergency drugs are injected into someone whose heart is in fibrillation--they don't circulate to the tissues. You have to do CPR to 'stir them up'. And if Ambu-ing brings your pt back--how can you NOT stick an ETTube in there? Is THAT ethical?

The problem is that the 'code' has been turned into a menu. Pt's and their families imagine that they can select one aspect but not the entire procedure and still have some effect.

So some folks naturally recoil from the idea that Papa or Gramma is naturally going to die; they want to save her life. But they also recoil from the pictures of rib-crushing CPR and endless days in ICU on the Vent. So they try, without understanding the way the entire procedure works together, to design a customized 'code' that expresses their reluctance to let the Pt actually die but quarantees that the Pt won't live.

Dumb Dumb Dumb!!!! Obviously a situation created by hospital administrations trying to offer 'customer service'.

Grumble Grumble Grumble

Papaw John

babynurselsa, RN · Sep 21, 2005

Well papaw I do agree with you. I just look at it this way. This is what makes the family comfortable regardless of the fact we aren't gonna change the outcome.

I don't have too much trouble giving that round of drugs and calling it. I have a whole lot more trouble cracking every single rib on some little old 97 year old 78 pound granny with bone ca, breast ca who I am also not gonna be able to change th outcome for.

I would have more trouble with " well do one round of CPR." I have not encountered this.

pricklypear · Sep 22, 2005

We have a very different way of dealing with DNR in Ohio. There is a DNR-CC and a DNR-A. THe DNR-CC denotes only comfort care, no treatment with meds, TF, intubation....the DNR-A denotes that we treat everything up to the arrest, so we can push meds but no intubation or compressions/defib. Sometimes the families state the patient is a DNR-A but can be intubated or they will allow one round of defib/compresions which really screws everyone up and requires the nurses to do a lot of teaching for the family members. This is the first state I have worked in with 2 different DNR designations; I still have to look up the policies after 1 year.

I wish we had those catagories around here. Most of the time it's pretty cut and dry, but there have been problems. It seems to be different at the 2 different hospitals I've worked at, also. At one, "DNR -comfort care only" were clearly written. If the patient was just "DNR" we treated everything until arrest. Where I am now, it's not so clear. You have to try to pick up from the chart, or report exactly how far we're going with this patient. Which is scary. The doctors can't seem to agree in some cases, either. You might call one about no urine, he says "why are you calling, the patient's a DNR!!" But the other Dr on the case might want to talk to the family about dialysis at 2am. "Just because they're a DNR doesn't mean don't treat" I've just learned to assume the patient will be treated agressively up till the end, unless I hear differently.

To the original question

1) Yes, it implies no intubation or chest compressions

Drugs are iffy - depends on the patient here (at least at my hospital)

Papaw - I think it's the family's way of dealing with guilt. They know grampa isn't going to live, but they have to assure themselves that at least they "tried"