DNR...is there a grey area?

nurse4theplanet, RN · Dec 11, 2005

After reading several post in the Biggest Mistake thread. I have a question. IF someone is DNR that does that mean in all sceniarios? OR say they are DNR due to a terminal illness then it would go without saying according to the pts advance directives. So lets say a patient is choking, you do they hemilich (spelling) and the object does not come dislodged, they go unconscience, they have a DNR. Are we to do nothing at this point? Im wondering if there is a grey area with this subject. Or maybe I am confused. I have worked with only a handful of DNR's so any information or clarifications would be great.

that's a good question and I would sure like the answer. Seems to me if they were dying because they had aspirated as opposed to their disease process, then you would be obligated to do everything possible to prevent death...but how could you without chest compressions, etc.????

fluffwad · Dec 11, 2005

i spend a lot of time explaining the dnr to families.

dnr does not stand for do not treat. i get a lot of calls from some er nurse who calls the nursing home with "why did you send him here? he's a dnr what do you expect us to do with him?" there always seems to be one who is riding the high horse.

answer: treat the patient in accordance with the familie's wishes.

if your patient is choking on his lunch, you do the heimlich on him. in the case of a dnr, i'd say you stop treating when the heart stops.

there is still this mindset in the community that signing the dnr is like signing a death certificate. there are even a few nurses out there that think if a patient is dnr that they don't get antibiotics and that we're allowed to neglect them to death.

in most nursing homes, cpr is very basic: no defibrillator, no crash cart with all the meds, etc......but you really need to know ahead of time if a patient is dnr or not because its not all that unusual to walk in and find that someone has passed away. calling the poa and asking them to make that kind of decision suddenly isn't realistic, and probably wouldn't hold up legally.

unfortunately, most of this is a gray area.......there are always a lot of possiblities and most folks don't get the luxury of a cut & dried scenario.

ch10 · Dec 11, 2005

Yes it is a grey area. However, if the DNR was made whilst the patient was an inpatient then it needs to be reviewed weekly by their consultant. Changes could happen and the patients condition might have improved.

If for example there is a directive that the he/she dont want to be resusitated because of other co-morbid conditions then it must be upheld. If there are no other co-morbid conditions surely when he/she is discharged, DNR is no longer viable. I would have thought that DNR ruling is reviewed at all times unless indicated otherwise.

ch10

Trauma Columnist · Dec 11, 2005

A nursing home in our area got in trouble (and heavily fined with admin all fired) over this very issue. They had a resident who was a DNR. He was at lunch and choked on a piece of food. The staff stood around arguing over whether to do the Heimlich. In the meantime, the resident died! In my book, that is murder. It is going to the courts. DNR does not mean do not treat. In Illinois, the Illinois Dept of Health has a new DNR form that allows for three choices:

1. Do everything.

2. Do nothing

In a pre-arrest state:

3. Do you want drugs, intubation, etc., prior to actual cardiopulmonary arrest.

Daytonite, BSN, RN · Dec 11, 2005

A patient choking on a foreign body, such as food, is not exactly a natural occurrence, so I think the answer here would be that you try your darndest to dislodge the foreign object in the person's throat. You can't start CPR because it will be ineffective since the patient is getting no oxygen. Think back to your CPR guidelines. . .you can't procede to the "C" of the ABCs until you can do "A" and "B" and so you continue to try to dislodge the obstruction. Abdominal and chest thrusts are used to attempt to dislodge the obstruction and are not to keep the heart going at that point.

If the person is hospitalized I would work on trying to remove the obstruction, call a code for assistance and let the doctor who shows up make a decision on whether or not to continue with a code blue after telling him the scenario. To my way of thinking DNR is for more natural, logical occurrences of the pathway of death. This becomes interesting in the case of people with advanced Alzheimer's or MS though, doesn't it? If the patient is outside the hospital and out in public, he's going to be resusitated unless your state has DNR guidelines in place for the paramedics to follow.