RRT on DNR

[bxh5164]

Last night I worked night shift on my medsurg/stroke/oncology floor. A nurse came out to the nurse's station and asked if any of the senior nurses were around. I said no, why? She said I think my patient is dying. I said is she a DNR? Is she comfort care? She's like she's a DNR and they were kind of expecting her but not so soon. I said oh and we ran back to the room. I walked in and she was unresponsive agonal breathing HR in 30s and I asked do you want a RRT? I knew nothing about the patient besides she was a DNR? The nurse looked at me and then she said ya. I called a RRT and when they showed up she had already passed. The nurse had sat on her for over an hour "while she was on her way out." As she called it. The RRT team was like why would you call a RRT on a DNR?? It was a change in patient status and her RN told me to. The RN blamed me. And said I called it. I told my manager about the situation. Just because she's a DNR doesn't mean you don't do anything. Did I do something wrong??? The nurse is notable for not being competent i knew nothing but the patient was all but passed when I walked in.

[IrishIzCPNP, MSN, RN, APRN, NP]

So you knew she was a DNR but called RRT anyway? What did you want them to do? You didn't know anything about her but you knew she was DNR...then again so did the nurse who was assigned to her who said to call the RRT.

[nrsang97, BSN, RN]

No you didn't do anything wrong. I am a RRT nurse. Honestly if they were DNR or comfort care there is not anything we can do but keep the pt comfortable.

To be honest I get all kinds of calls that aren't necessary, but I still do my best to help. I have had RRT on hospice patients for many reasons like uncontrolled pain, family concerns, and falls. We do what we can within limitations of the code status.

Honestly is seems like the nurse should have called the family of the pt, and had them come in. I would rather have a nurse call me for something unnecessary than not call for something significant.

[Gooselady, BSN, RN]

No, IMO you did nothing wrong.

We have RRT at my previous job. They are a RESOURCE as much as they are critical care nurses here to save a life. Even so, most nurses 'used' RRT only for full CPR patients, and felt like it was a waste to consult RRT for any reason with a DNR patient.

We had an end stage COPDer, a DNR, go into bronchospasm. She was terrified and gasping. We called RRT to help with her symptoms, so in calling her doc we could give the doc specific information and request specific treatments.

Even so, we had RRT responders give us the stink eye on a variety of occasions. Some felt their function was ONLY to rush in and initiate a transfer to ICU. Sometimes you'll get flack no matter what the policy and procedures lay out in black and white. Since this was a patient you weren't familiar with, and the primary RN seemed clueless, calling RRT 'just in case' is reasonable. At least you didn't call a code!

So IMO this was NOT a mistaken judgement call on your part. What it does illustrate is misunderstanding of the staff, including RRT as a whole as to the proper function of RRT. Take this to your manager as an issue to address with staff education. We needed to do this off and on, as it is human nature to get rigid and into stupid power struggles. As often RRT needed to get it together as much as RN staff :)

It's a valuable learning experience, anyway. Find out if RRT has any specific role in managing severe symptoms of a DNR patient, it will definitely help the whole staff when a situation like this happens again, and it will :)

[akulahawkRN, ADN, RN, EMT-P]

Unfortunately people can mistakenly think that DNR status means "Do Not Treat." These patients can absolutely be treated for their problem... as long as it's not "resuscitation" as defined by state law or facility policy. As I personally see it, calling RRT for the patient wasn't a bad thing because it very well could have been that there was something that could have been done to either make the patient more comfortable or perhaps that agonal breathing was "just" something simple like a blocked airway that just by changing head position changes things around. RRT might even be able to confirm for you that the patient is indeed in terminal decline and remind you that perhaps family should be called.

I'm but a new grad, but every time I had a patient as a student where RRT was called for a patient of mine, the RRT nurse was very helpful.

[bxh5164]

The patient wasn't expected to pass so suddenly. It was a change in status. She was alert and talking earlier in the shift. Something should have been done way earlier in the night when she realized things were headed that way

[Gooselady, BSN, RN]

I agree. The RN assigned to her should have informed the charge nurse and the family, at least. It's concerning she neglected to let her coworkers know about such a big clinical change.

[vanilla bean]

I am also part of an RRT team & the first time I responded to an RRT call on a patient that was DNR, I was shaking my head wondering why. One of my colleagues reminded me that DNR does not mean Do Not TREAT, and she was absolutely right. There is plenty we can do to resolve issues like hypotension or respiratory distress that does not conflict with a DNR order and may make the patient more comfortable in their final hours or days. Not every DNR patient admitted to the hospital will die during their stay with us. If they experience a complication during their admission that can be resolved by prompt treatment, perhaps we should try to provide that care.

[Twinmom06, ASN, APN]

my grandmother was a no code for 25 years. If the attitude was to not treat a DNR then she'd have died 24 years ago instead of last year.

[dudette10, MSN, RN]

The nurse you were working with does not understand DNR if she sat on a change in a patient condition until the patient died. If, for example, a DNR starts showing signs of a PE (anxiety, sudden SOB), it can be diagnosed and treated without violating the DNR wishes.

[blondy2061h, MSN, RN]

You absolutely can call a RR on a DNR. DNR means "do not code" and the whole point of a RR is to stop it from becoming a code. You can be a DNR and not be actively dying and have no change in treatment up until the point that you do actually die. Some DNR patients even want to be intubated. The RR can be used to get stat labs, an abg, and EKG, give cardiac meds, apply O2, intubate if the patient allows it, start bipap, get a CT scan if needed, push meds that may help like dextrose and bicarb, start pressors, draw cultures, start antibiotics, get x-rays. I could go on forever.

Even for patients that are only comfort care, you can still call a RR if the patient seems uncomfortable and you're not getting anywhere with the managing physician- at least at my facility.

You did the right thing, it sounds like. That nurse should not have been bullying you. If the patient wanted everything done, she should not have sat on him for an hour til he was minutes away from dying.

[motherof3sons]

The nurse who was assigned(not you) to the patient dropped the ball long before you called in the RRT. It makes you wonder what happened all the hours prior to the patient passing???