do you mask/bag during DNI

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I had a patient code today and he was DNI, but NOT DNR, medications and chest compression were used but not intubation.

whats the point right? well I was wondering if we should ever be bagging considering his wishes and also risk of aspiration secondary to vommiting (least of his worries at that point I know) but what if he survives?

Just asking?

what do you think?

Thanks

Specializes in Critical Care.
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 Eventually the pt rescinded the DNR until her pacer was put in (really for the daughter's peace of mind, she was ready to go either way).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.

In general the requirement of a POA is to ensure that the patient's wishes are being followed, a POA who is intentionally directing care that goes against the patient's wishes but rather following what they think is best for them has disqualified themselves from POA rights.

I've been getting the impression we're talking about a very narrow definition of "code", but your example seems confusing. Your facility doesn't allow patient to be DNI, the can only be full code or DNR presumably based on the (false) idea that all code interventions require intubation, yet by your description they wouldn't even get temporary pacing in that situation even though they don't require intubation to be temporarily paced,given atropine, etc. Why would you remove options that don't require intubation just because the patient wants to be DNI?

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...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.

I think this problem is in part why the US is seeing such a proliferation of palliative care programs. As a palliative care NP, I am involved in may of the ICU admissions in my regional hospital. Often I am asked to consult in the ER upon arrival to meet with the family and discuss the poor prognosis and many times having an honest conversation can help the family understand that care may be futile. Some families opt to admit to the hospital for comfort care instead of aggressive measures.

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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.

I don't agree with you. Why would you pressure an old women into changing her decision, just because her daughter is upset? Your job is to advocate for your patient. If anything, give accurate, not opinionated, information so that she can give an informed decision.

I also think it's wrong for you to go against your husbands wishes, because you are afraid.

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Specializes in Quality, Cardiac Stepdown, MICU.
I don't agree with you. Why would you pressure an old women into changing her decision, just because her daughter is upset? Your job is to advocate for your patient. If anything, give accurate, not opinionated, information so that she can give an informed decision.

I respect your disagreement. Maybe I didn't characterize the situation well. I made it clear to everyone involved that it was the patient's decision. "I'm OK with it either way," she said. "But mom, I don't want to lose you just while we're waiting for this procedure to happen," the adult daughter insisted They asked me exactly what would/would not happen if she were DNR, vs. if she were full code, while she waited the 4 days or so for her procedure to be done, and I answered them factually. "I'm OK with it [being DNR], but it upsets her, so I'm going to do this if it makes her feel better, until after the surgery. Here, cut my bracelet off," she said, offering me her hand.

My first responsibility is to my patient, and I made everyone aware of that. But as a mother, her choice was to give her daughter peace of mind, and I respected that as well. The point I was making is that even when people make their own decisions, sometimes they will forgo what they would do alone, and choose something different for the sake of those they love. Either way, if it is done with love and not from pressure, it gets my support. If I get even a whiff that the pt isn't happy with their choice, I speak to them again after the family leaves.

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According to multiple studies, there is no improvement in neurologically intact survival to hospital discharge, if you intubate during a code. Many hospitals no longer routinely intubate until the patient gets ROSC or they are having difficulty ventilating the pt or it's a primary respiratory issue. Chest rise is chest rise. Intubation is the number one thing that pulls us off the chest during CPR. It seems hard to justify routine intubation during CPR.

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The policy where I work is all or nothing. I had a patient that had an extensive cardiac history but on this admission the problems were primarily respiratory. His family wanted him to be intubated if indicated but did not want chest compressions. It was a weird situation and the physician convinced them to go with the full code route but I'm not sure how I feel about full code or DNR with no gray areas

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Specializes in Cardiac Critical care.

I found that many pts were confused about DNR's and living Wills. When we admit pt's we cover so much information that by the time we get to living wills and DNR they say "not interested". Unfortunately, it is one of the most important decisions they will ever make and it should not be a decision made with out a complete discussion/explanation of all the issues. Once, we had a pt code on the unit who was a complete DNR but, his wife was his durable power of attorney and decided she wanted a full code done. I remember rolling that red cart in and lots of nurses looking at me like "what do we do"? We did a full code... we were unable to resuscitate him. In this case the options had been explained, discussed, and decided by the pt. He had been recently dx with aggressive prostate ca and receiving tx when he developed a arrhythmia.He was a young 58 yrs old and although he had a tough battle ahead no one expected a arrhythmia to develop or a clot. His wife thought she agreed with his decision but, when the aweful moment happened she wasn't ready....I understood her pain. Her need for us to immediately code him. This is one area where I believe every Hospital could use work on improving the discussion and decision making of DNR's.

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Specializes in ICU.
I found that many pts were confused about DNR's and living Wills. When we admit pt's we cover so much information that by the time we get to living wills and DNR they say "not interested". Unfortunately, it is one of the most important decisions they will ever make and it should not be a decision made with out a complete discussion/explanation of all the issues. Once, we had a pt code on the unit who was a complete DNR but, his wife was his durable power of attorney and decided she wanted a full code done. I remember rolling that red cart in and lots of nurses looking at me like "what do we do"? We did a full code... we were unable to resuscitate him. In this case the options had been explained, discussed, and decided by the pt. He had been recently dx with aggressive prostate ca and receiving tx when he developed a arrhythmia.He was a young 58 yrs old and although he had a tough battle ahead no one expected a arrhythmia to develop or a clot. His wife thought she agreed with his decision but, when the aweful moment happened she wasn't ready....I understood her pain. Her need for us to immediately code him. This is one area where I believe every Hospital could use work on improving the discussion and decision making of DNR's.

I have coded a DNR because of family wishes, too. It is all kinds of messed up, IMO, but if the person dies, he is not going to sue. If he dies and his family wanted him coded, they might. They would probably lose, but not before making the whole thing a huge PR nightmare for the hospital, so I do understand why we code DNRs. I wish the system worked differently.

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