DNRs and ACLS

[GardenDove]

Can a DNR/No Code receive anything else from ACLS, other than being shocked or intubated, or does everything need to be ordered specifically by a doc?

I was talking to my co-worker last night, I had a DNR pt go into stable V-tach last night just after shift change. While I was in the room with pt, someone called the doc and we gave IV lopressor which converted him back. Then he got 150mg of amiodorone, then an amiodorone drip.

My coworker and I are both newer to the unit, and where she worked previously on a Tele floor, her charge nurse was the one to take over in the event of emergencies.

So, if it had been the middle of the night and I was alone and a pt had a perfusing V-tach, could I have given 150 of Amiodorone under ACLS immediately to a DNR to convert him back?

[Bethy-lynn]

Where I work, we have sort of an "all or nothing" policy when it comes to DNR (i.e. they either want to be a full code, or not, we don't do chem codes, or intubation only). In fact, according to our policy, we can't intubate someone that is a DNR. However, that doesn't mean that we couldn't use lido or amioderone on someone in stable v-tach. According to acls guidlines, these could be given per protocol without calling a physician first. I think that in this case, it could almost be thought of as a comfort measure, not necessarily heroic (cause let's face it, even stable v-tach can be a little uncomfortable). Really, what would be the difference between giving someone morphine and nitro for chest pain, which could also be life-saving, and doing this? I think that if ever in doubt, it is always safer to call the MD. Also, this should serve as a reminder to all of us to be sure to have very frank and Honest conversations with our pts and fams.

[GardenDove]

I just got off the phone with my manager. She said every case was individual, and that a no code pt can be treated under ACLS at times, if you want to convert their rythm, for example, as in the case with my pt. So, I would have been able to do the first thing on the algorythm before calling the doc in the case of stable V-tach, which can quickly progress to unstable V-tach. Once someone is in unstable V-tach or V-fib, you definately are not to call a code or perform CPR on a no-code, but before that is a gray area where you need to use your judgement.

[TazziRN, RN]

I just read the rest of the thread that was written since I posted.

Yes, if you have a DNR pt with a rhythm change, you can treat it. Until the pt loses his pulse and/or respirations, you are not resuscitating.

[one_speed]

As mentioned in previous posts, the act of cardioversion itself isn't considered a heroic act, any more than fluid boluses (fliud rescuscitation) are. Treating a person before they degenerate into a true resuscitation case is often what they present to the ER with (or admitted to the hospital for) in the first place.

In our hospital (Ontario, Canada) ER and CCU RN's are ACLS trained and in an arrest situation we are delegated to diagnose disrythmias, administer life saving drugs, and defibrillate. Delegate being the key word. ACLS recert

q 3 years, CAR (Cardiac Arrest Response - a 5 hour mini ACLS course so the hospital doesn't have to pay us for three days to attend a mandatory ACLS course)) recert annually to be delegated the act as per ACLS protocol.

A large forcus of ACLS (and CAR) is on disrythmia recognition and disease progression. While cardioversion is not a delegatable act, ACLS covers it so we can recognise abnormal cardiac rythms, be aware of the progression of the disease, PREPARE FOR CARDIOVERSION and the MD can follow through with it.

In my experience (and I think that this is standard across ontario, many patients (ie LTC) come to the ER with treatment directives rather than a simple yes or no DNAR that can direct staff to send them to the ER if they need to for fluids, iv atibiotics, and other comfort measures. More detailed

directives can be passed on by the POA to the physician later on.

Ian

[Tweety, BSN, RN]

Sounds like your unit has standing orders to treat arrythmias, which includes the ACLS protocols. Really any monitored unit should have these, so as not to waste precious time.

I work in med-surg (we have tele as well) and we only use ACLS during codes. We do have standing orders that go along with our telemetry patients, but it's not ACLS...it's give this and call the MD.

A DNR can be treated for arrhythmias (why else would they be on a monitor that would spot them), but for asystole of course.

[Rnandsoccermom]

DNR doesn't mean do not treat. All it actually means is that if you walk in and find them dead you do nothing.

That being said, if you continue to draw labs, do xrays, use telemerty etc... it all HAS to be treated if there is a problem. That is from a legality sandpoint. The only way you do nothing at all is in a terminal case at the families or pts request.

Vtach is treatable unless it terminates into asystole, then you would stop.

[AnnieOaklyRN, BSN, RN, EMT-P]

Remember DNR means do not resuscitate not do not treat.

swtooth

[suzanne4, RN]

To clarify a few things: Following ACLS protocol in your hospital is not an physician's order and may even differ from what your standing orders are. The ACLS Protocal will not stand up for you in a court of law as being a medical order. You need to have a written standing order in place to follow ACLS guidelines for each individual problem that occurs. Same way that intubation used to be a required practice area in ACLS, but in most facilities in the US, the nurse is not covered to do that.

DNR stands for Do Not Resucitate meaning that nothing is to be done for them, including drugs to convert them unless specifically authorized by the physician. UNLESS you have an actual standing order on your unit.

The order should state exactly what the physician wants you to do. Whether compressions or no, drugs or not, intubation or not. Some patients want to have food but nothing done, and this could be considered doing something. And open you to litagation.

A key thing to remember is that ACLS is a standard, it is not a specific physician or provider order. You are required to follow the policies and procedures that your facility has in place. In sure that your facility has something in writing and that is what needs to be followed..it is your responsibility to know what is in the P and P manual for your facility and your unit. Anything else does not stand up in a court of law.

[GardenDove]

OK, I'm going to send my manger a link to this thread. Thanks for the post Suzanne4. It sounds like this whole issue is muddy waters still for me.

[suzanne4, RN]

Another thing to think about is why the patient is a DNR in the first place? Why did they want that or the family want that? If the patient is terminal with lung Ca, and did not want anything done to prolong things because of pain, and then they were treated, they have every right to be mad or upset.

And the other thing is that stable V-tach does not automatically go into unstable V-tach; ther are patients that actually walk around with stable V-tach and tolerate it just fine.

And as a new nurse, remember that a standard is not a physician order, ACLS automatically does not cover you in your facility unless it is specified in the Policy and Procedure manual for the hospital, or specific standing order for your unit. Do use it without an order can be construed as practicing medicine without a license.

Hope that this helps.