do you mask/bag during DNI

uRNmyway, ASN, RN · Apr 25, 2014

DNI means DNI. Do not intubate. If that's the patient's wish, then that's what you do.

I think to a certain extent, I might want the same. When I think of being coded, the idea of ending up in ICU (God forbid, LTAC), with a trach and a vent in PVS....ugh...I just shudder to think of it. But that doesn't mean that I wouldn't want any attempt to save my life.

Advanced Practice Columnist / Guide · Apr 25, 2014

I think that's a big problem with the way providers discuss goals of care with family members. The fact that we still offer options such as intubation/advanced airway, chest compression, and medication administration in a patient's code status as if they are separate parts of a cafeteria menu just doesn't make sense when we know that cardiopulmonary resuscitation in this age of sophisticated ACLS algorhythms prove that all of those steps go hand in hand.

umcRN, BSN, RN · Apr 28, 2014

Our unit uses the term "limited code" which has advantages and disadvantages. Often times I think it makes things confusing for the parents (this is peds). They are basically given a list of things we "could" do and they choose what they do and do not want. This can range from giving code meds but no compression's (point?), clearing/suctioning the airway/bagging but no intubation, starting vasoactive drips and giving fluid but no epi boluses or compressions to being a complete AND (allow natural death term is used rather than DNR). I've seen it all. I've seen one "limited code" that said we could do everything for the patient EXCEPT place a chest tube...??? what doctor wrote that order I have no idea.

In any case to answer your question if I had a patient who was a DNI but NOT an AND/DNR then yes I would suction/bag them and increase noninvasive respiratory support if indicated.

ICUPrincessNurse · May 1, 2014

I loathe DNI most of all when it comes to a code situation. We'll do Bi-Pap like whoa to try to avoid intubation but we try to be pretty clear to the patients/families that insist on full code but no intubation that in the event of a true cardiac arrest that it is basically impossible to effectively code someone without intubating them and we encourage them to consider what they really want out of a DNR status and what we can do for comfort instead of intubating. It's just a matter of education and expectation management sometimes.

Biffbradford · May 1, 2014

If I was early on the scene, then I'd bag 'em initially until the bi-pap arrives or the team decides that I should stop.

delphine22 · May 2, 2014

My husband woke up once during an emergency intubation and he said it was the most terrifying experience of his life -- feels like you are drowning, which is also one of his worst fears. He doesn't want to be intubated under any circumstances. Lucky for two things: my hospital does not accept DNI -- you are either all the way or not -- and as his wife, I get the say, and I know sometimes these things are necessary.

But in response to the OP, I would definitely bag, that's noninvasive and exactly in line with the pt's wishes. I'd do bipap too.

MunoRN, RN · May 2, 2014

My husband woke up once during an emergency intubation and he said it was the most terrifying experience of his life -- feels like you are drowning, which is also one of his worst fears. He doesn't want to be intubated under any circumstances. Lucky for two things: my hospital does not accept DNI -- you are either all the way or not -- and as his wife, I get the say, and I know sometimes these things are necessary.

A little of topic, but are saying you would direct staff to intubate your husband against his wishes?

Cuddleswithpuddles · May 2, 2014

I think that's a big problem with the way providers discuss goals of care with family members. The fact that we still offer options such as intubation/advanced airway, chest compression, and medication administration in a patient's code status as if they are separate parts of a cafeteria menu just doesn't make sense when we know that cardiopulmonary resuscitation in this age of sophisticated ACLS algorhythms prove that all of those steps go hand in hand.

Yes! Yes! Yes! Some of the a la carte choices families make basically do nothing. I spoke to one of our doctors and she says that America is unique in allowing families to direct clinical decisions that do not make clinical sense. Can anyone comment on this? Are modified codes as prevalent in other countries?

delphine22 · May 2, 2014

A little of topic, but are saying you would direct staff to intubate your husband against his wishes?

Hell yes. He knows I would, too. I'd just make sure I'm present for any sedation vacation so I could help calm him down when he wakes up.

Sometimes when people have irrational fears they need someone to be strong for them. I was that person for him when I was just his wife, but now as a nurse too I have the knowledge and confidence to back it up.

Relating this to patient care, you just have to level with them. I had a pt who wanted to be DNR (she was over 90) because she didn't want her ribs broken during chest compressions -- a reasonable line of thinking at her age. She was having long pauses and it would be a few days before the pacer was going to be put in. Her daughter asked, what would we do if her heart stopped again but didn't restart? Big fat nothing. They tried to lobby for a drugs-only code, but I had to explain to her that if I'm not doing compressions to move blood around, the drugs would sit in her arm and do nothing. Eventually the pt rescinded the DNR until her pacer was put in (really for the daughter's peace of mind, she was ready to go either way).

That brings me to another slightly unrelated point. Sometimes these decisions are made by the patient, but according to the wishes of their loved ones. Like in my husband's case, he may be afraid of intubation, but no way am I letting that fear take him away from me and our two small children if it could save his life. And my pt was at peace with herself and her original decision, but it was upsetting her beloved daughter so much -- now that the risk of dying was so close and we had the means to save her but weren't going to do so -- that she changed her mind for her.

Advanced Practice Columnist / Guide · May 2, 2014

Yes! Yes! Yes! Some of the a la carte choices families make basically do nothing. I spoke to one of our doctors and she says that America is unique in allowing families to direct clinical decisions that do not make clinical sense. Can anyone comment on this? Are modified codes as prevalent in other countries?

Our medical center once had a guest speaker for one of our daily ICU conference with the residents doing their critical care rotation, critical care fellows, and NP's. The guy is a director of Critical Care Medicine at a similarly large medical center in the East Coast.

He trained in the UK and practiced there for a while prior to coming to the US. What he said is that providers approach goals of care differently in that country. The moment a patient is brought to the ED with a condition that qualifies for critical care hospital admission, the provider weighs the benefits of treatment vs favorable outcomes given the patient's age, co-morbidities, and severity of illness. Right in the ED, the providers would outright state to the family that no further options are to be offered in terms of curative treatment because the patient is too high risk and have very poor chance of recovery.

I'm not necessarily advocating this thought in the face of some popular belief that these are akin to "death panels"...but we are admitting lots of ICU patients who we know will not do well despite our best efforts and we are "scared" to be upfront about these facts to families. It could be fear of legal retaliation or just our culture of not giving up that easy but it results in a lot of unnecessary pain and suffering on both the patient and the family.

MunoRN, RN · May 2, 2014

Yes! Yes! Yes! Some of the a la carte choices families make basically do nothing. I spoke to one of our doctors and she says that America is unique in allowing families to direct clinical decisions that do not make clinical sense. Can anyone comment on this? Are modified codes as prevalent in other countries?

I've worked places where all services are offered despite medical futility, although where I work now it's not all that unusual for a physician to make a patient DNR based on medical futility despite the patient/family wanting to be full code, we also withdraw other treatments based on medical futility, sometimes against family wishes.

I don't agree however that wanting to be DNI yet otherwise full code doesn't make sense. I work in the ICU as well as a rapid response nurse and I've frequently provided "code"/ACLS interventions that don't require intubation.