Just found out my partner's dad is a DNR

atomic_pedal · Jul 28, 2012

Wow, that's a really terrible thing to say Bluedevil My partner and I are both nurses and we are also caregivers for her grandfather. Code status was one of the first discussions we had with the entire family.

heron, ASN, RN · Jul 28, 2012

May I also suggest that you get info about your local EMS rules. In my city, even signed/witnessed advance directives won't prevent an inappropriate resuscitation. We have to have a specific out-of-hospital DNR form physically available in the home, or EMS assumes full code until told otherwise by an MD. They can't just take your word for it. If your partner's dad is sick enough to need resuscitating, he's unlikely to be able to speak for himself. Your local fire dept., emergency dept., or dept. of health might be places to start looking.

nurseprnRN, BSN, RN · Jul 28, 2012

in our state there is a mechanism for the pcp to fill out a form for dnr. it comes with a duplicate for the family/tack up on the fridge or whatever, a copy for the local ems, and an armband that's numbered to match the order sheet for the patient. if the patient changes his mind for any reason all you have to do is remove the armband. this makes it good for any setting, not just the home.

ask your local ems what they recommend. if there is no statewide protocol like ours, and dnr is really real, get it signed by all involved (md, patient, poa), make a bazillion copies, and make sure you distribute them to all caregiver offices, local ems, have one in your car, and have a couple in your bag for when he goes to the hospital. even if they have one in his medical record from last admission, it won't see the light of day out of medical records (even if electronic) until too late, so have one to shove in front of the eyes of the admitting team.

Advanced Practice Columnist / Guide · Jul 28, 2012

GrnTea makes a good point. While advance directives and living wills do state a person's wishes regarding medical care, EMS does not accept these and will provide all the necessary interventions in an emergency. What will ensure that these do not happen in a person who wishes to be a "DNR" is to make sure a state-approved form is filled out. In California, for instance, the POLST form is all-encompassing and is honored in every setting and situations the person may happen to be in.

For more info, see links:

http://www.capolst.org/documents/CAPOLSTform2011v13web_005.pdf

http://www.capolst.org/

nurseprnRN, BSN, RN · Jul 28, 2012

or don't make the phone call right away. sit and hold his hand and be present with him as he passes. after it's done, wash him, dress him in his best pjs, and then call the police to report a death at home. even better, get him on hospice (i'll bet he meets a lot of the criteria already) and they will pronounce him. then you just call the funeral home.

hospice eligibility criteria for common diagnoses

als

dyspnea @ rest

vital capacity less than 30%

declines artificial ventilation

critical nutritional impairment

rapid disease progression or complication in the preceding 12 months

cancer

clinical finding of malignancy with widespread, aggressive or metastatic disease

patient no longer seeking curative treatment

palliative performance scale equal to or less than 70

dementia

inability to ambulate or dress without assistance

urinary and fecal incontinence, intermittent or constant

no consistent meaningful verbal communication

one of the following within the last 12 months:

aspiration pneumonia

pyelonephritis or other uti

septicemia

decubitus ulcers, multiple stage 3-4

inability to maintain sufficient fluid and calorie intake

fever, recurrent after antibiotics

failure to thrive

palliative performance scale equal to or less than 40% (mainly in bed, requires assistance with adls)

body mass index below 22kg/m2; bmi=703 x (patient's weight in pounds) + {height in inches)2

the patient declines or is not responding to enteral or parenteral nutritional support

heart disease

poor response to optimal treatment with diuretics, vasodilators, or ace inhibitors

presence of nyha class iv chf or refractory angina

ejection fraction less than 20% (helpful but not required)

not a candidate for, or has declined, revascularization procedures

liver disease

pt prolonged more than five seconds over control or inr greater than 1.5

serum albumin less than 2.5gm/dl

must have one of the following:

ascites

hepatic encephalopathy

history of recurrent variceal bleeding

spontaneous bacterial peritonitis

hepatorenal syndrome

multiple sclerosis

critical nutritional impairment

rapid disease progression or life threatening complications in the preceding 12 months

critically impaired breathing

non-specific terminal illness

recent rapid clinical decline and disease progression

decline in functional status

weight loss

dependence on assistance for two or more adls

recurrent aspiration

increase in er visits, hospitalizations or physician contact

progression of cognitive impairment

progression pressure ulcers in spite of optimal care

dysphagia with recurrent aspiration

parkinson's

critical nutritional impairment

rapid disease progression or complications in the preceding12 months

pulmonary disease

decreased functional capacity

evidence of disabling dyspnea @ rest, or with minimal exertion

poor response to bronchodilators

progression of disease as evidenced by increasing visits to physician, er, or hospital for pulmonary infections

hypoxemia on room air less than 88% by oximetry

fev1 less than 30% (helpful but not required)

renal failure

patient is not seeking dialysis

creatinine clearance less than 10cc/min {

serum creatinine greater than 8.0mg/dl {>6.0mg/dl for diabetics

not a candidate for dialysis

stroke

palliative performance scale of 40% or less

poor nutritional status with weight loss over 10% in the past months or 7.5% in the past three months

coma with three of the following on third day of coma:

abnormal brain stem response

absent verbal responses

absent withdrawal response to pain

serum creatinine greater than 1.5

patients are also eligible if they meet some of the above criteria but have significant comorbidities or rapid decline suggesting a six-month or less prognosis.

even if the patient does not meet any of these conditions, he or she may still be eligible for hospice if based on documented data and in the judgment of the physician the life expectancy is six months or less.

tigerlogic · Jul 28, 2012

DNRs at my hospital are sometime really specific: don't intubate but chest compressions ok. Aggressive medical treatment ok; no shock. Or some such thing. If there are specifics, track them down sooner.

Esme12, ASN, BSN, RN · Jul 28, 2012

dnr's are not "valid" outside of a hospital setting although the ems may respect his wishes. the out of state poa is only valid to advocate for the patient when declared incompetent or incapable to make their wishes known. i would check with your state while dad is able to make his own decisions and ask his pcp to fill out the necessary paper work. many states now have out of hospital dnr's ..........the state of ma is "comfort care" that allow ems to not perform life saving measures. without this even the power of attorney can't,technically, stop lifesaving measures out side of the hospital setting. we cannot offer legal advice as per the terms of service but i would check with his pcp or your local ems to see what they have to say.

as far as the poa.....the patient himself should have his own legal papers, or a copy, in his possession for that time in need. all my sisters have copies of the poa for my mom even though there is only one sister with the "official" power.

comfort care - do not resuscitate (dnr) order verification program the comfort care/do not resuscitate (cc/dnr) form is the only means for ambulance services, emts and paramedics to verify that a patient has a valid dnr. if emts are not shown a properly executed cc/dnr form for the patient, emts are required to resuscitate per their protocols. if they are shown a properly executed cc/dnr form for the patient, emts will provide only palliative care to the patient during transport.

http://www.mass.gov/eohhs/provider/guidelines-resources/clinical-treatment/comfort-care/

ionatan · Jul 28, 2012

Why don't you just talk to dad about it? It's his decision not someone out of state.

The dad has made it clear he does not want CPR performed on him if something happens. He has heart disease, but other than that he functions pretty well on his own and is doing pretty well overall. He has not been declared incompetent. If something happens, I don't want to be questioned about why I did not perform CPR with nothing to back myself up. I also don't want EMTs starting CPR if it is not something he wants. I don't know why they don't have the paperwork here. That is why I'm trying to get everything in order.

ionatan · Jul 28, 2012

in our state there is a mechanism for the pcp to fill out a form for dnr. it comes with a duplicate for the family/tack up on the fridge or whatever, a copy for the local ems, and an armband that's numbered to match the order sheet for the patient. if the patient changes his mind for any reason all you have to do is remove the armband. this makes it good for any setting, not just the home.

ask your local ems what they recommend. if there is no statewide protocol like ours, and dnr is really real, get it signed by all involved (md, patient, poa), make a bazillion copies, and make sure you distribute them to all caregiver offices, local ems, have one in your car, and have a couple in your bag for when he goes to the hospital. even if they have one in his medical record from last admission, it won't see the light of day out of medical records (even if electronic) until too late, so have one to shove in front of the eyes of the admitting team.

thanks for the advice grntea and everybody else. this has been very helpful for me. i live in pa so i will try to find out what the emts would need to see to withhold cpr.

Melissa0181 · Jul 28, 2012

Wouldn't you HAVE to have a copy of DNR paperwork? From what I understood (which may be inaccurate) any healthcare provider would treat the client has a full code until they have a physical copy of the DNR paperwork.

CapeCodMermaid, RN · Jul 29, 2012

When I did homecare orwhen we discharged SNF patients home, we would tell the clients the same thing: keep your file of life with your list of meds and your signed comfort care on the refrigerator door. The EMTs on Cape were all trained to look on the fridge door for the documents. Be prepared.

MunoRN, RN · Jul 29, 2012

PA is a POLST state, I would suggest you have him fill that out with his MD at his next appointment. At least in my state, advanced directives and even a POA don't mean a whole lot, a POLST is really the only thing that will ensure his wishes are met in various situations.

http://www.ohsu.edu/polst/index.htm