No dnr

VictoriaGayle · Sep 12, 2012

I really want to see what someone who knows more about this subject says, that is a very interesting question.

I remember I was once told that all hospice patients are comfort care/dnr but I have no idea if that is true or not, nor am I sure where one could find such information.

tewdles, RN · Sep 12, 2012

If the patient does not have a valid DNR (called Comfort One in Alaska), you are required to perform CPR...just like EMS would have to when you call them. Your license requires this. In some states it is possible to obtain a verbal DNR from the DPOA and contact the physician for a verbal DNR during the visit, but you will want to research your state laws. In most states hospice must notify the local law enforcement agency of an expected death in the patient home. If that paper work is not completed the police and possibly the ME may be required to attend the home death, they may require an autopsy. Best to have all of those ducks in a row before the death.

If the patient is actively dying during your visit and does not have a valid DNR call EMS and get them to the hospital asap.

VictoriaGayle · Sep 13, 2012

If the patient does not have a valid DNR (called Comfort One in Alaska), you are required to perform CPR...just like EMS would have to when you call them. Your license requires this. In some states it is possible to obtain a verbal DNR from the DPOA and contact the physician for a verbal DNR during the visit, but you will want to research your state laws. In most states hospice must notify the local law enforcement agency of an expected death in the patient home. If that paper work is not completed the police and possibly the ME may be required to attend the home death, they may require an autopsy. Best to have all of those ducks in a row before the death.
If the patient is actively dying during your visit and does not have a valid DNR call EMS and get them to the hospital asap.

So does hospice not require its patients to be DNR? Someone at work told me that, and it sounded crazy to me. This person wasn't a nurse and had never worked for hospice so I don't know why they would claim to be an authority on the matter, but I wonder if anyone else has heard that? Is it a prevalent rumor?

akulahawkRN, ADN, RN, EMT-P · Sep 13, 2012

If a patient is admitted to hospice but does not have a dnr and they are actively dying in front of you what do you do? I answered I'd call 911 and start CPR because by not signing a dnr patient is saying they want to be resuscitated. I was told that was wrong answer and we stay with the pt and make them comfortable until they die. I understand that's the meaning of hospice but what about our licenses? Doesn't not performing CPR on a patient without a dnr in place have legal reprocussions?

If your patient is admitted to hospice, usually they have a DNR order somewhere in the paperwork that admits them to hospice. The wording may not specifically say "Do Not Resuscitate" but there should be language in the order admitting the patient to hospice that effectively means that resuscitation should not be attempted for this particular patient. So possibly a better answer might have been to "I should check the paperwork for presence of a DNR or similar order and only if not finding any such order would I called 911 and start CPR. Otherwise I would stay with the patient until they passed." Usually a patient on hospice is "understood" to be a DNR.

Prehospital providers would not hesitate to start CPR in the absence of a valid DNR order for a valid POLST order. They would be doing what is necessary to protect their own certificates and licenses based on the policies and protocols that they must follow. They do understand that hospice patients typically do not normally want to have resuscitative measures started, but they are limited by what they have in their own policies and protocols.

akulahawkRN, ADN, RN, EMT-P · Sep 13, 2012

So does hospice not require its patients to be DNR? Someone at work told me that, and it sounded crazy to me. This person wasn't a nurse and had never worked for hospice so I don't know why they would claim to be an authority on the matter, but I wonder if anyone else has heard that? Is it a prevalent rumor?

Some hospice programs may have an "understanding" that their patients are effectively DNR, even in absence of an actual DNR order.

sclpn · Sep 13, 2012

Where I work pts in the home setting are not forced to be a DNR because pts/families know that 911 is a life line and they will call even if they have been told to call hospice first for anything. In our Hospice House it is our policy that the DNR has to be singed for pts to come there, even for respite or symptom control, even if the plan is to return home later. Ive had a few actively dying pts on admit/scheduled visit or that just started crashing right in front of me. I offered to call 911. Most every family decided to forgo CPR and make pt comfortable,as they knew CPR was futile and wouldnt cure the cancer or whatever they had. Ive also had families to find the pt expired and call 911. Most of the time EMT's saw the debilited condition of the pt and called ER doc for a verbal order of DNR. CPR is against the hospice phillosphy. Hospice doesnt treat death. Most pts/families have already had the whole CPR/DNR conversation prior to being refered to hospice. Its usually the younger pts that have problems with signing it and sometimes even talking about it. Essentially, I believe, its up to the hospice if they force their pts to sign DNR.

tewdles, RN · Sep 13, 2012

In Ohio, Michigan, and Alaska there is no "presumed" DNR. They either have legal DNR documentation or they do not. DNR status is not required for hospice services. Hospice does not force people to sign DNR paperwork.

If the patient is a full code we start CPR when appropriate.

VictoriaGayle · Sep 14, 2012

This is a really interesting thread.

I guess if I ever get to be a hospice nurse I should remember to double check state laws and the programs standards as it seems to vary incase I'm in a situation like OP.

westieluv · Sep 14, 2012

Maybe this is a state by state thing, but I live in Michigan and you would definitely do CPR and call 911 on a patient without a legal DNR in place. We had very vew patients who refused to sign the DNR, but it happens sometimes, especially with younger patients who can't accept that they are dying. A DNR is a very scary concept to wrap your head around for some people. We even had a few cases, though, where an elderly patient who was not competent to make healthcare decisions, had no living will, and had no family involved, remained a DNR until a court-appointed guardian was in place to sign a formal DNR. This is serious stuff and, at least in my state, it is never just assumed that a hospice patient is DNR status.

enchantmentdis, BSN, RN · Sep 15, 2012

I work for a large nation-wide hospice. Even if a patient is a full code, the hospice does not refuse to admit the pt because we can still help with symptoms, and of course, hospices do want to make money, too. We don't turn away full code pts, however, from the beginning we gradually have the "isn't it time to make him/her a DNR" discussion with the family. It can take days, weeks, or months to convince them that extraordinary measures will likely prolong the patient's suffering, and the result will be the same---death, but probably a painful death. Some families keep the patient a DNR in place until we arrive for the death visit, and once we say the patient has died, they usually give up and decide against CPR--thank goodness. Once a patient of mine died on the toilet (was a full coder). Her family was hysterical and wanted her revived, but i gently took them aside, firmly clasped their hands, and said, "she is gone, be brave enough to not put her through any more indignities." Of course, they cried and guilt permeated the room. Then i called the chaplain. The patient was put back to bed, cleaned up, and by the time the mortuary attendants arrived the family was coping better.

We are not required to take CPR to work at this particular hospice (though i have ACLS); and we are told to not initiate CPR. From the beginning, we tell families that our staff will NOT perform CPR on the pt-- that they have to call 911 for that; and that, if they are taken to the ER, hospice will not foot the bill or pay for any treatment unless it's related to the hospice diagnosis. And they will be revoked from the hospice during their hospital stay. Often they come right back to hospice, and, thankfully, with a DNR in place. It all sounds very cold but they signed up for hospice and it's about letting the patient leave with dignity and respect. In the hospitals, it would behoove the staff to have the hospice discussion long before the patient goes home so the family is prepared.

enchantmentdis, BSN, RN · Sep 16, 2012

As a rule our hospice puts actively dying patients on continuous care for symptoms management--excessive secretions, dyspnea, pain, terminal restlessness, caregiver breakdown, teaching of meds and dying process, etc.... Often once they have a nurse or HHA for 8 hour shifts in the home; the chaplain arrives to minister; and the MSW comes to enforce the no hospitalization rule in a gentle way; the family members usually give up on the DNR. Also, our hospice doctors and NPs visit patients, and reinforce the idea that going to the hospital is a bad idea.