Death and Dying in the ICU

divaRN* · May 30, 2011

I work in an ICU in the north. Once a patient is a DNR/ DNI or CMO that is what they are unless condtiion changes then the MD will readdress code status with the family. Until the point of DNR/DNI our MDs offer every option possible along with a discussion about code status. We present all of the options to the patient and family, then allow them to make their decision. Sometimes the code status will be tailored for a specific patient. Exaple. Pt who has PEG Trach and vent. Pt had been refusing dialysis. Family dynamic involved. Our code status for her is DNR if no pulse. if pulse. no escalation of care. maintain vent and tube feedings. no blood draws. Max levo 5mcg/kg/hr. anything above and beyond what was writen was not wanted.

ICUenthusiast · May 30, 2011

I work out west so I don't know how you want to categorize me but:

I was wondering what experiences people have had with DNR, DNI, and comfort measures in the ICU setting. What type of communication do your doctors have with patients and their families about end of life issues?

We use a LOT of family conferences. We, the primary nurses of a patient, are also pretty aggressive with our discussions about DNR/switching to DNR with family. We have had, fortunately, great social workers and a palliative team that has taught us well how to express quality of life, prognosis, and the pt's wishes to patient's families. You'd think the pt's wishes would direct their care if incapacitated and put into ICU setting but....... sadly, the family will try to override the care as I'll explain in a second.

Is it appropriate to intubate a patient that has a DNR but not a DNI? Do doctors hold up advance directives or do they push families to make more aggressive decisions? Do doctors talk about prognosis with families before starting aggressive treatments like CCVH/dialysis or HFOV? Is code status even discussed with patients/families when patients are admitted? Are pressors indicated for a DNR patient? Does your facility have a set DNR protocol or is it a big shade of gray for everyone who comes in?

1) Physicians will discuss code status and aggressive treatments when it's possible first. Sometimes, we just get a patient found down, no prior known POA, code status, advanced directives, and at that point, we have to treat them as a full code that would want everything. If family is available, then it is discussed first. Unless, again, the situation is absolutely dire, family is unreachable, then the physician will begin what's necessary if care has not yet been well delineated.

2) DNR does not necessarily mean DNI. We have DNR's that say chemical code only, DNI, can intubate, etc. Some are as educated as to say do not give pressors. If the patient just has DNR, intubation can be considered a possibility if they go into respiratory distress. Technically, that is not resuscitating at that point. This is why we have DNI status patients. This is the same for pressors. Sometimes, we also do this (provided the pt has not said "DNI") to keep the pt alive for family to come in. Usually this is a conversation about how their family members wishes are DNR etc., they are doing poorly, and they are on life support. Family will ask to keep them alive just until they can all come in and say good bye, and then we switch to comfort care. UNFORTUNATELY, if a patient loses the ability to direct his care, and even if he is documented DNI, in our state, the POA automatically goes to the closest, eldest living relative. And we have had many cases where they direct us to go against their family member's wishes. It's a crappy situation all around when that happens.

If and when comfort measures are implemented what types of things do you stop or continue to do? Do you still take vital signs or draw labs? Are these patients sent to the floor or are they left in the ICU for continuity of care?

We don't draw blood anymore, but we do take vitals. Vitals is very helpful for us to direct if they need more medication to keep them comfortable.. e.g. if they're starting to desat slowly, you don't want them to be showing signs of air hunger while family is in watching them pass. Our number 1 goal is to give the family and pt as much uninterrupted time as possible, only interrupting to specifically intervene to keep their loved one comfortable (medications, maybe suction the mouth so they don't aspirate secretions, etc). Now mind you on ICU most of our patients don't take more than a few hours to pass on when they are turned to comfort care because it's usually withdrawing life support. I know outside of the ICU comfort care patients have held on for days and then they may go in and turn the pt, something we don't do. Very rarely do we have a comfort care patient that was not a withdrawal of life support patient as well.

Darkfield · May 30, 2011

I work in the northeast. I think our attendings are very good about addressing code status with the families when it starts looking bad or when the pt is very elderly or has a poor quality of life. If the family states they want to do DNI/DNR or comfort care, our docs are usually very good. We have more problems with families who want to push and push and push. The worst cases are with families that have a lot of faith and they think faith is that God will do a miracle at the last moment, not that God will do whatever He sees fit. We had a woman maxed on five pressors, pulmonary hemorrhaging, that we coded six times in twenty-four hours because the family would not accept death.

I've seen a pt made dnr over family objections one time because of medical futility (on echmo, hfov, sats in the 70's).

Our comfort care patients are kept in the ICU if death looks likely soon. If they weren't on pressors/intubated, they go to the floor sometimes. The only I do for comfort care pts is q8 vitals and t&p. We don't have good education and/or policies on comfort care and I think we could work on that. We do a great job until then, and then it's seems like it is sort of up to the RN what they want to do.

**LaurelRN, MSN · Jun 1, 2011

I work in the Southeast in a general ICU. We do not have a DNR policy and quite honesty we really need one. There always seems to be at least one patient in our unit that has some sort of "code status" issue going on. Our MD's are NOT good at discussing or even broaching the subject of code status. I personally think our docs push people into more aggressive decisions and sort of "lead them on" about how sick their loved ones are and what the chances of survival truly are.

As for treatments- of the patient is withdrawl of life support- everything is withdrawn- (we s RNs' keep our monitors on and can see the one at the desk- so we turn off the one in the room. But temps, labs, etc- are all withdrawn. We do go in to turn (carefully!! no terminal turns please!), or suction.

If the patient is not a withdraw- it is up to the MD to make the decision on what treatments are done. Sometimes we will stop everything but the vent or only the vent and tube feeds...but almost always- if we stop one- we stop all.

mcleanl · Jun 1, 2011

I too have worked in the North and the South. I notice a difference between obtaining DNR/DNI's.....in the Northern States it was readily addressed.....not so in the Southern states that I have worked. Darkfield mentioned the religious aspect and I have to agree....it seems to me (and I am stating what I have observed) that it is more difficult to discuss DNR status with highly religious families and there (IMO) tends to be more deeply religious people in the South. There is one local hospital that has changed the term DNR to "AND" which stands for "allow natural death." I love this term because it often allows families to look at the situation froma different midset. My hospital has not adopted this yet but I hope they do. I am interested to hear what your experience is.

nikkicoliCCRN · Jun 2, 2011

I too have worked in the North and the South. I notice a difference between obtaining DNR/DNI's.....in the Northern States it was readily addressed.....not so in the Southern states that I have worked. Darkfield mentioned the religious aspect and I have to agree....it seems to me (and I am stating what I have observed) that it is more difficult to discuss DNR status with highly religious families and there (IMO) tends to be more deeply religious people in the South. There is one local hospital that has changed the term DNR to "AND" which stands for "allow natural death." I love this term because it often allows families to look at the situation froma different midset. My hospital has not adopted this yet but I hope they do. I am interested to hear what your experience is.

Thank you so much for this. I strongly agree. I would think it would be different. If you are so strong in your beliefs of religion you would be comforted by the peace of death. It's just not the case. I also feel that doctors avoid the conversation because they don't want to deal with it. I like that term. Thanks so much for sharing.

nikkicoliCCRN · Jun 2, 2011

I work in the Southeast in a general ICU. We do not have a DNR policy and quite honesty we really need one. There always seems to be at least one patient in our unit that has some sort of "code status" issue going on. Our MD's are NOT good at discussing or even broaching the subject of code status. I personally think our docs push people into more aggressive decisions and sort of "lead them on" about how sick their loved ones are and what the chances of survival truly are.
As for treatments- of the patient is withdrawl of life support- everything is withdrawn- (we s RNs' keep our monitors on and can see the one at the desk- so we turn off the one in the room. But temps, labs, etc- are all withdrawn. We do go in to turn (carefully!! no terminal turns please!), or suction.
If the patient is not a withdraw- it is up to the MD to make the decision on what treatments are done. Sometimes we will stop everything but the vent or only the vent and tube feeds...but almost always- if we stop one- we stop all.

This is something else that I find. There is no real "DNR policy". There is this gray area of "understanding" what DNR is. I also feel that we do things just to say we are doing them. We have a few doctors that are good, but we do have some who just keep pushing. I feel so frustrated sometimes. :mad: :mad: :mad:

funkywoman · Jun 28, 2011

I have had the opportunity to work north and south and even in Korea due to marrying military. Have worked DNR places that meant comfort measures, have worked places where DNR we would intubate. One place I worked EVERYONE had a CODE sheet. That was the best because everyone was on the same page, family and/or patient were given a choice from the point of admission. EVERY SINGLE patient had a code sheet, was kept on the front of the MD order section. It was an orange sheet that spelled it all out. Doc (admitting) simply circled what he wanted ...yes or no.... mechanical ventilation, pressors, code meds, intubation, chest compressions, cardioversion. There was no doubt as to what to do and it made my job much easier. The last place I worked I could never get a straight answer wether DNR meant DNI.......scary