invasive procedures during comfort cares?

nutella, MSN, RN · Jul 11, 2016

As far as I know you can not be officially CMO in the ER. Of course a patient can be DNR/DNI but that is not the same as CMO. And there is of course the question of futility if a patient is in the active dying process and death appears imminent. It sounds that the prescriber/physician/ attending wanted to order tests etc while the patient was DNR but not CMO. Perhaps it was futile but just DNR does not exclude any tests as you know. The problem is when a patient / family decides to elect CMO but is in the ER or had an elective procedure in a cath lab or had surgery within the last 24 hours.

Nurses can experience morale dilemma over situations like the one you describe while the provider may feel there is a morale obligation to investigate the situation and order tests.

MunoRN, RN · Jul 11, 2016

The decision about what medical orders are initiated is solely up to the Physicians, family members cannot enter orders for medical tests, treatments, etc, so I'm not sure what you're referring to about the S.O. entering these orders. Ultimately it's up to the physician to determine if these tests and treatments are medically futile or if they are appropriate.

As far as catheters in comfort care, that's based on a case by case assessment of whether or not this would bring the patient more comfort than discomfort.

Wile E Coyote, ASN, RN · Jul 11, 2016

I think an in and out cath for urine is far enough down the list of painful/distressing procedures, particularly on an individual with a GCS of 3, that the documented evidence that this patient was once victimized by someone with any remaining level of access upped the moral obligation to rule out murder. Yeah, it's a stretch based upon the information you shared, but it's not clearly unwarranted. I'd start giving push back if more aggressive interventions, such as intubation were considered. Therefore, yes, I would have explained that the doctor ordered a urine sample, and the usual steps that lead from that.

Skylar86 · Jul 11, 2016

I think an in and out cath for urine is far enough down the list of painful/distressing procedures, particularly on an individual with a GCS of 3, that the documented evidence that this patient was once victimized by someone with any remaining level of access upped the moral obligation to rule out murder. Yeah, it's a stretch based upon the information you shared, but it's not clearly unwarranted. I'd start giving push back if more aggressive interventions, such as intubation were considered. Therefore, yes, I would have explained that the doctor ordered a urine sample, and the usual steps that lead from that.

I suppose I should have used a different title for this thread. Unnecessary is more the word I was looking for rather than invasive. I realise nothing is going to be distressing for someone who already has a gcs of 3 however the time it would take to put in the IDUC for the patient is time taken away from the family to have with their loved one. Just like the 15min it took for the patient to have the CT. Imagine she had died in the CT room without the family there?

I just found it all upsetting.

ArtClassRN, ADN, RN · Jul 11, 2016

Issues like this arise very often with people who are newly transitioning to comfort care. Especially if they are actively dying.

Questioning orders, getting information from and counseling family members, and prioritizing interventions are all fairly common and necessary steps. My advice to students and others I am precepting is to try and maintain professionalism and not become emotionally involved.

The complaint about body language and attitude sounds justified based on your description. It is perfectly fine to advocate for the patient and discuss your concerns calmly with the family and others on the medical team. Rolling your eyes, crying, or other types of outbursts when these difficult discussions do not go your way are not helpful.