DDNR Violation :(

[nicenurselpn, LPN]

I just wanted to see what other nurses would think of what actually happened at work one day last week............

We have a patient who was made a ddnr by his parents. He is severely mr/vegatative state, severe seizures, trach. He has times where he will actually desat really really low. One time when I was his nurse his O2 sats dropped to 14%, and since he is a ddnr, I complied with the order and held his hand. He has specifics on his ddnr, we can suction his trach or mouth if needed, no cpt and absolutely no cpr or bagged breaths via his trach. He still gets all of his meds, and his tube feedings. However, there is no order for Moriphine.

One day last week, another nurse went to that unit to check on him (he is her "baby"), she walked in his room and found the ambubag sitting on his chest, and the other nurse actually admitted that she had given his bagged breaths. I told the other nurse, that she needed to report this and the other nurse could get into alot of trouble.

What do you guys think?

NiceNurse LPN

[canesdukegirl, BSN, RN]

I think that you should discuss the finer points of a DNR order with your NM first. I did a little look-see at my state's laws regarding DNR, and to my surprise I see that it can vary. In your case, assisted breaths may not be considered a violation, but if he was shocked, it would clearly be a violation. This is a great question, and I am glad you brought it up.

[LouisVRN, RN]

Honestly, this is my worst nightmare. You wouldn't believe how many patients I have found with advanced directives on their charts but no one has bothered to look at them and change their code status as an inpatient. I can't imagine anything more horrifying.

I do believe at the very least you could talk to risk management they should be able to advise you.

[tyvin, BSN, RN]

If the DNR is specific to no bagging then absolutely the incident should be reported.

I would also like to add someone should advocate for the prn MS for comfort, etc... This would come in handy should he start any irregular breathing, shows signs of pain etc... It's a comfort measure just as suctioning is IMO. A very low dose prn should be implemented for his comfort should it become necessary.

[KarmaWiseRaven]

Well i for one carry a DNR and we would not be having this talk. That nurse would be fired or worse and your facility would be talking to my lawyer and my family would own your place employment or laughing their way to the bank because of a Multi Yes A Multi Million Dollar Law Suit. DNR's and Advanced Directives are set in place for a reason. Choose to ignore them like some Facility's and so many Nurse's do be ready for the action's to follow. These are my thoughts use them as you wish

[nicenurselpn, LPN]

Per the family's wishes there is to be absolutely no ambubagging this person.His dnr is pretty detailed and specific.

NiceNurse LPN

[P_RN, ADN, RN]

Be very careful in giving information about your patient online please.

[ObtundedRN, BSN, RN]

I'm confused. Did the patient actually arrest? Because that is when a DNR applies. If he is still breathing, and still has a heart beat, then you should be allowed to give O2 and give assisted breaths. I understand if it was respiratory arrest it may apply, but if it is just respiratory distress then you should treat the patient. DNR doesn't equal do not treat.

Or did I miss something in your OP?

[GHGoonette, BSN, RN]

Considering that the instructions are so detailed, then I agree, this nurse was in violation. I also think a wise UM should counsel her regarding it. I would hate to think of a nurse losing her job because of compassion; as a PACU RN, I know how terrifying it is to a patient not to be able to breathe.

As I said, counselling and a verbal warning should be in order. Hopefully your hospital's management sees it in the same light.

[systoly]

I'd be very careful with second hand information. To ensure all staff understands the situation, ask your DON if you can give an in service on this patient's advance directives and consequences of violating them.

[Spika RN]

Was going to comment but everything was said. But I have to agree it P_RN you gave quit a bit of detail here it should be a little more vague then it was but very interesting non the less as stated science DNR order for this patient is so detailed and the ambu bag was used it is violation of the DNR order because they do not need to be codeing for the DNR to hold water

[BabyLady, BSN, RN]

If the DNR is specific to no bagging then absolutely the incident should be reported.

I would also like to add someone should advocate for the prn MS for comfort, etc... This would come in handy should he start any irregular breathing, shows signs of pain etc... It's a comfort measure just as suctioning is IMO. A very low dose prn should be implemented for his comfort should it become necessary.

I agree with this completely.

I cannot imagine letting someone sit there and suffocate to death...if their sats were low and they seemed peaceful, then by all means, let nature take over.

But if they were showing signs of air hunger or struggling and suctioning didn't work, to me, an ambu-bag would be a measure of comfort rather than life saving.

This is why I think hospice nurses are worth their weight in gold.