DNR question

  1. Hey, I had a patient yesterday and wanted to share a story, then get everyone's opinion.
    A 53 year old lady with a 40 pack/yr smoking history was admitted with end-stage pulm fibrosis and stage 4 lung ca. She was made a DNR. She had obviously been a beautiful woman before lung disease got her, she had very mysterious eyes and long gray hair, very sweet and kind disposition. I was her nurse for the shift before she died.

    Anyway, she pulled her oxygen off before I realized what she had done. Her sats dropped into the low 40s (with an excellent pleth that correlated with her EKG) and her rhythm changed to a-fib between 170-210, BP 60/30. Her family asked if this was the end, I said yes and then her husband said "Is there anything you can do to slow her heart rate down and bring her blood pressure up?"....loaded question for sure.

    I told him I'd speak to the MD, we conferred and the decision was made to give her some diltiazem, start saline @ 100cc/h and place her back on her neosynephrine gtt. I did all this and eventually she returned to her baseline, which was poor to begin with.

    Her doctor came in that morning and was upset over what had happened.
    My thoughts are:
    1. A DNR does not translate to Do Not Treat. I wasn't resuscitating her and if she had been in EMD it would have been a different story.
    2. Her HCPOA/husband clearly stated what he wanted me to do.
    3. I spoke with the on-call physician and reached the decision that we acted upon.

    When my shift was over, I told her that I'd be thinking about her while I drove home....she reached out, grabbed my hand and said "I'll be thinking about you too, honey". It really moved me, I told her not to bother thinking about me and to focus on herself and her family. She smiled and that's the last I saw of her.

    I'm not in trouble, her doctor isn't angry at me and I'm definitely not looking for anything resembling legal advice about DNRs. What I want to know is: do you think I did the right thing? why or why not?

    I've been thinking about it almost constantly.
    Last edit by getoverit on Sep 10, '09
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    About getoverit, BSN, RN, EMT-P

    Joined: Dec '07; Posts: 448; Likes: 783
    MICU/CCU, fire department paramedic; from US
    Specialty: 18 year(s) of experience in ER/ICU/Flight


  3. by   cardiacmadeline
    Yep, DNR does not mean do not treat. I would have done the same thing. If they did not want the patient treated, she should have been on comfort cares.
  4. by   athena55
    You gave compassionate, caring, professional care to a family whose loved one was actively dying.
  5. by   RNperdiem
    You did everything I would have done.
    A DNR is not the same thing as withdrawing support.
  6. by   rachelgeorgina
    Everyone has made it clear that DNR does NOT correlate to do not treat. In Australia we often have patients that are NFR (not for resuscitation, the equivalent of DNR) but FOR "MET" calls. I believe MET calls are the Australian version of a rapid response, MET standing for "Medical Emergency Team".

    Basically, unless they are in the process of actively, currently dying, we treat to our best extent.

    You did the right thing
  7. by   freiheit
    yes...:heartbeatyou do the ryt thing....because DNR as per medical procedure which seeks to restore cardiac and/or respiratory function to individuals who have sustained a cardiac and/or respiratory arrest it is like
    you can suction the airway, administer oxygen, position for comfort, splint or immobilize, control bleeding, provide pain medication, provide emotional support, and contact other appropriate health care providers.....:redpinkhe
  8. by   AnnieNHRN
    I think what happened here is that the family did not have a clear plan in place with the doctor when she was made a DNR. This is the time when a doctor should talk about what the family's/pt's wishes are. What can they expect during her last days/weeks? What do they want done? He also needs to discuss hospice and what comfort measures would entail.
    I am sorry you were put in the situation you were in. I understand when a pt is monitored and has vitals signs like you stated you were obligated to call the doctor. My question is why was this terminally ill pt with a DNR on a monitor? I think a quiet hospice room would have been more appropriate.
  9. by   tencat
    You didn't do anything wrong. As others have said, DNR doesn't mean don't treat. It is a pity she wasn't on hospice at home or in an inpatient unit. Her husband wanted you to do something, and you did. No one would deny help to a patient if the patient or a family member wanted it. I wouldn't worry about her doc and his/her feelings on the subject. He/she wasn't at the patient's bedside all night....you were. You did a good job.
  10. by   Tait
    You did the right thing. Same thing I would have done.

  11. by   highlandlass1592
    I have to disagree with the other posters here. If it was the end, as you say..you did prevented her from being able to complete the dying cycle. Replacing the oxygen on her face would be a comfort measure. You put her on a vasopressor to raise her blood pressure which is a form of resusitation. Yes, you could have made her comfortable and still not resusucitated her. What stinks is as another poster stated, there was no clear definition of the DNR. When the MD made this pt a DNR, it should have been spelled out as to what interventions they would and would not want. Her husband also put you in a difficult position by asking you to try to stop her body from dying, I'm guessing this was a coping mechanism on his part..which is totally understandable.

    You made a comment that "DNR doesn't mean do not treat". What do you think a DNR is supposed to mean? By definition, do not resuscitate is meant to refer to dealing with the dying process. It means that you don't stop the process, you don't hurry it along, you just allow it to happen. You still offer support to your patient and family...you still utilize nursing interventions but you don't do something to stop the patient from dying..which is exactly what you did.

    A few people here have commented that she should have been in hospice. We deal with DNR's in all aspect of healthcare, not just hospice. One person mentioned the patient should have been on "comfort care". In some institutions, DNR is equivalent to comfort care. I think this is a learning experience for you. And this may be an excellent opportunity for your institution to look at how they define DNR...at my institution, a process was implemented to more accurately define treatment options for patients who wish for a DNR status. It really clears up any grey areas. You could be a champion for starting this process at your institution.
  12. by   highlandlass1592
    Quote from RNperdiem
    You did everything I would have done.
    A DNR is not the same thing as withdrawing support.
    How would you define DNR?? It means not to resuscitate, not to interrupt the dying process by providing medical intervention. If someone starts to die, you don't stop them. Withdrawal of support is also a form of a DNR...it means you stop all medical interventions you are currently using to also allow the dying process to take place.
  13. by   RNperdiem
    For me DNR means not trying to bring back the dead. In a simpler time, dead was defined as no heartbeat and no breathing.
    No CPR and no defibrillation. Otherwise, we treat the DNR's just like any other ICU patient.
    DNR or no DNR, the human mortality rate remains fixed at 100%.
  14. by   nessa_5555
    I live in a small town 45 minutes east of Toronto Ontario Canada. The facilities (Retirement homes, Nursing Homes, Hospitals, Home) the DNR forms that are filled out by the patient or SDM (Substitue Decision Maker) clearly state what kind of DNR they would like. Either it be Comfort Measures Only, No Intubation, No CPR etc. This is a legal document. It clearly states what the patient wants done when death is certain. I do agree with what you did though. I would have done the same thing. Not only did you assess the situation correctly, you consulted with the on-call Physician. There should be no question in your mind about what you did. You showed compassion for the family, for the client. Bravo to you