No dnr

caroladybelle, BSN, RN · Sep 16, 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?

It is literally illegal in many states to require a hospice pt to be a DNR.Admittedly, that policy makes little sense, but it is considered a form of discrimination in providing care.I personally don't care about "unwritten" or "informally understood" policies..... And in most cases, neither does the law. If there is not a written or formally witnessed DNR order, your license is in jeopardy if you do not initiate life saving measures. Much like the illegality of the old "slow codes".

aphillipi · Sep 16, 2012

I emailed my board of nursing and got a reply yesterday pretty much saying follow your company's policy... Not really the answer I was looking for. Their policy is no CPR but it really feels wrong to me. if the patient hasn't signed a dnr, and they've been given the opportunity, that means they want to be rescusitated. I just can't wrap my mind around how it's ok to not do CPR. Any other ideas of who I could contact about this other than my BON?

curiousauntie · Sep 17, 2012

In NJ the DNR must be signed by the patient or POA and the MD, even hospice patients. If there is no bedside DNR, the healthcare provider in the home must start CPR and call 911. We have quite a few patients without DNRs but we address this as frequently as we can. Either the nurse or the social worker will continue teaching to the patient and family, and as the patient declines they usually will get to the point that they understand and accept a DNR and the reasons behind it.

Char711 · Sep 24, 2016

PLEASE NOTE : FORCED DNR PAPERWORK IS ILLEGAL AND AGAINST MEDICARE RULES !!!!! HOSPICES DO THIS FOR THEIR OWN "CONVIENCE" AND TRAIN THEIR STAFF TO BELIEVE THIS !!!!

My mom is currently in Hospice Of Cincinnati and we were FORCED to sign DNR to be admitted and ws told Medicare WOULD NOT PAY UNLESS WE DID.........

We did not agree with basically little to no care under DNR and that hospice would not even provide like blood ect if hers got low ect ......SOME THINGS CAN BE "FIXED" and ARE NOT THAT invasive to do even IF you are dying .......ITS HOSPICE NOT A FUNERAL HOME !!!! ???

BECAUSE of that and mom not at immediate deaths door we were opposed to the FORCED DNR even though we would NOT choose to make mom suffer and are always with her unlike some patients.........

I WAS REPEATEDLY TOLD they could force this .......I simply GOOGLED "do you have to be DNR in hospice" .......AND YOU DO NOT !!!!!!!!! A Medicare survey taker interviewed us at hospice and was appalled and pissed they were telling people MEDICAREwon't pay ect IF you are not DNR CAUSE ITS A TOTAL LIE !!!!

THE FACILITY HAD TOLD PEOPLE IN ALL 4 FACILITIES THIS FOR YEARS !!!!!!!!!!! THE LADY OVER THE ONE WHERE WE ARE CAME AND APOLOGIZED AND TOLD ME THIS !!!!!!!!!! THEY CLAIM.....THEY DID NOT KNOW ANY BETTER AND THEY MUST REVISE THEIR WHOLE POLICIES !!!!!!!!! BECAUSE OF.......ME........I TOLD HER ........OMG JUST GOOGLE IT ?

THEY GOT IN TROUBLE BECAUSE OF THIS.......BE FOREWARNED !!!!!!!! YOU DO NOT ......HAVE TO BE DNR IN HOSPICE AND CAN SIGN OUT AND GET TREATMENT AND BE READMITTED ........BUT THE HOSPITAL HAS TO KEEP YOU LIKE 24 HOURS OR SO TO BE READMITTED BACK TO HOSPICE ..........

HOSPICES TELL PEOPLE THIS BECAUSE ......ITS EASIER FOR .....THEM ......AS ANOTHER HOSPICE DID TELL ME.........SOME PEOPLE WANT DNR SO THEY JUST FORCE IT ON EVERYONE ........AND MY OWN OPINION IS.......IF YOU SIGNED A NEDICAID PAPER YOU DIE SOONER AND THE STATE RECOVERS THE PERSONS HOUSE IF THEY OWN ONE AND HOSPICE GETS REIMBURSED .......ITS A REAL ESTATE AGENCY .......

I find it sad the people are NOT encouraged to eat or anything really .....NOT force fed but not even encouraged ..........they are treated like dead upon admission. Additionally .....we have been told many other lies ect too and its NOT a "nice place"......it only appears that way on the cover. Its TEMPORARY AND EXPENSIVE and has ate up our entire small savings so mom is being sent home FOR US to care for her and HOSPICE to get the money and was provided a dirty metal rental bed with a piece of foam on it for her to lay constant . Only scathing complaints got her a mattress upgrade and its still unsanitary and sucks.......

I would prefer home health if possible but dont know how to get the other stuff covered by insurance ect.........

BUT FORCED DNR IN HOSPICE IS NOT BY MEDICARE STANDARDS !!!!!!!!!! ANYONE DOING THAT AND MEDICARE FINDS OUT........FACES CONSEQUENCES.......

I FOUND OUT CAUSE I WAS PISSED AND RESEARCHED IT......AND .....LUCKILY WAS TIME FOR MEDICARE TO DO A SURVEY THERE ........THE LADY WASNT "HAPPY" AT ALL TO HEAR ABOUT FORCED DNR !!!!!!!!

HOSPICES NEED TO NOT TELL THEIR STAFF ITS NORMAL OR OKAY......ITS ACTUALLY NOT !!!! SOUNDS LIKE LAWSUITS READY TO EXPLODE TO ME ???? NOT GOOD !!!!!!!!! WHAT IF......MANY IN HOSPICE WANTED NO DNR AND HOSPICE LET THEM DIE ???? WORKS BOTH WAYS .....LIKE SOME IGNORING A SIGNED DNR THAT WAS WILLINGLY SIGNED.........

Char711 · Sep 24, 2016

See my post regarding this !!!!!!! Its against medicare rules to force dnr paperwork in hospice or tell people they must sign it before they will pay !!!!!!!!!!! Hospices are forcing dnr wrongly !!!!!! Beware .......my mom is in hospice now and busted them doing this ........its wrong !!!!!!!! Makes it "easy" for hospice and they get repaid by medicaid faster when the state takes the patients home if they signed the medicaid papers !!!!!!!! There is incentive for the patient to die and provide the least care possible !!!! Hospice is a scam and racket........NOT a caring place at all if you look at the underbelly.........

Char711 · Sep 24, 2016

They better call medicare !!!!!! Forced dnr is against their rules !!!!!!!

tyvin, BSN, RN · Oct 5, 2016

You can have your DNR tailored to your needs. Will still have antibiotics, blood infusions, O2, suction, pain meds, etc... Or you can tailor your code to just CPR, no vent, no tubes, etc... If you break your leg and have a DNR they will still treat the leg. If you develop pneumonia they will treat it. People get the idea that the DNR is a death door document when it's not. I've had a few hospice patients go out of hospice and live for years. The thing is, if you're terminal and have a full code you might end up staring at a ceiling for a for a long time vented, and tubed.

Also, I've never heard of a hospice not feeding it's clients when the client is still eating. I've prepared many a meal with hospice clients. It just goes to show you that not all hospices are equal. Don't assume since you had a bad experience with one, that they're all alike. It's quite the contrary.

I will say that the DNR needs to be specific. I had an 81 year old female DNR who lived very comfortably in a LTC. She was not hospice. She got pneumonia and her doc gave her ABx and she was fine. A year later she got pneumonia again. I called her doc to find he was on vacation and there was another doc.

I explained the situation and had the previous Abx order in front of me. This doc started spewing of stats of if we didn't treat people in LTC with Abxs there would be a 40% or something like that decrease in patient population resulting in the ability to use the resources elsewhere. He wasn't going to give me what I wanted.

My girl lived and we won't go into that, but this doc actually tried to have me fired! He said I was actively tenacious when talking to him. Bye, bye sweetheart, my boss just shrugged her shoulders and told me to get out of her office. So; lesson here, be specific on any advanced directive or living will. When both documents are just black and white, it's up for interpretation.

nutella, MSN, RN · Oct 8, 2016

See my post regarding this !!!!!!! Its against medicare rules to force dnr paperwork in hospice or tell people they must sign it before they will pay !!!!!!!!!!! Hospices are forcing dnr wrongly !!!!!! Beware .......my mom is in hospice now and busted them doing this ........its wrong !!!!!!!! Makes it "easy" for hospice and they get repaid by medicaid faster when the state takes the patients home if they signed the medicaid papers !!!!!!!! There is incentive for the patient to die and provide the least care possible !!!! Hospice is a scam and racket........NOT a caring place at all if you look at the underbelly.........

You might want to consider that this is a nursing forum for nurses and not primarily disgruntled family members. While it is correct that a patient does not have to be DNR/DNI to be admitted to hospice in the community, a lot of nursing homes will not accept hospice care for a resident unless they are DNR/DNI , which is understandable.

Also, you state a lot of personal opinions, which do not become more true just because you repeat them, write in all caps and bold, or with several exclamation marks. It is true that you do not have to be DNR/DNI to be admitted to hospice. It is not true that all hospice are scam, you also confuse the medicaid part and just throw it in the mix for good measures. Your language is questionable.

Libby1987 · Oct 9, 2016

As a home health nurse who participated in the hospice transition, I apporached each patient individually.

For those with end stage cardiac, resp and/or renal disease etc I did have the prolonging the suffering discussion and encouraged DNR status for hospice admission for the humane sake of the patient.

For those with say a cancer dx but not otherwise in organ failure, we'd talk about the non permanency of the DNR, where if it wasn't the terminal illness causing the arrest then the POA could revoke the DNR and put the POLST away with the potential consequences explained, if they were POA of course. They can always make the call for resuscitative treatment and call 911, they were not losing that right by electing DNR. Chances are they weren't going to just randomly arrest before the disease process advanced and I didn't want them postponing much needed palliative symptom mgmt over an irrelevant technicality.

Finding a hospice agency who would admit a patient without a DNR was another challenge.

nutella, MSN, RN · Oct 10, 2016

As a home health nurse who participated in the hospice transition, I apporached each patient individually.
For those with end stage cardiac, resp and/or renal disease etc I did have the prolonging the suffering discussion and encouraged DNR status for hospice admission for the humane sake of the patient.
For those with say a cancer dx but not otherwise in organ failure, we'd talk about the non permanency of the DNR, where if it wasn't the terminal illness causing the arrest then the POA could revoke the DNR and put the POLST away with the potential consequences explained, if they were POA of course. They can always make the call for resuscitative treatment and call 911, they were not losing that right by electing DNR. Chances are they weren't going to just randomly arrest before the disease process advanced and I didn't want them postponing much needed palliative symptom mgmt over an irrelevant technicality.
Finding a hospice agency who would admit a patient without a DNR was another challenge.

What I found makes most sense when talking about advanced care directives with patients who are reluctant to change their code status despite the fact that the outcome will be negative to have a conversation that is tied into my general discussion with them.

I will ask "let's talk a little bit about what is important to you" and have them tell me a bit about their goals and wishes, preferences. Most people with advancing illness will mention that they do not want to suffer from pain or other symptoms in the future when the illness becomes worse. From there I point out - one way you can be in control of your future suffering is to avoid interventions that will not result in a good or positive outcome and will only add suffering. At that point I give them more information about the advanced care planning POLST or state DNR/DNI form and handouts to read about it. I encourage them to think about it and if they would like to talk to family to do that as well. It is usually important to point out that DNR/DNI does not mean the same as "do not treat" and I will also point out that if the patient has an advanced illness and comes to the hospital as a full code or becomes a full code again that symptom control will be more limited as physicians and nurses are concerned about side effects in a different way.

Often time, this discussion actually leads to some talk about when comfort becomes more important to patients and families and how to know when it is time to focus on comfort as opposed to extending time.

jdub6 · Oct 15, 2016

I emailed my board of nursing and got a reply yesterday pretty much saying follow your company's policy... Not really the answer I was looking for. Their policy is no CPR but it really feels wrong to me. if the patient hasn't signed a dnr, and they've been given the opportunity, that means they want to be rescusitated. I just can't wrap my mind around how it's ok to not do CPR. Any other ideas of who I could contact about this other than my BON?

There is a difference between requiring pts to sign a DNR (illegal as far as i know) and requiring staff to provide an intervention like CPR. Some hospices have policies that pts may be full code but that their staff does not provide CPR as it is not consistant with palliative care. Often this policy is explained in the consent forms signed by the pt/POA ("CPR is not consistent with the goals of hospice and may not be provided by hospice staff. Admission to hospice will not be refused if the patient desires CPR but CPR will not be provided by the hospice" or something similar. )

Sone hospices actually do not provide CPR certification. When you work for a hospital you are required to be certified and you are required to provide CPR when apprpriate by their policy. It is actually not the law or your license but company policy that requires those certified in BLS to provide it. Many hospices have a policy that outpatient staff witnessing cardiac arrest call 911. I do not know that any hospice would discipline a staff member for providing CPR, and you might be covered under good samaritan law if you do, but they do not require it. If your BON states to follow company policy i would be confident in doing so. Note that there is a big difference between having the family call 911 (what a prudent person who is not trained in CPR or not comfortable giving it- say if the person had known AIDS and is covered in blood and no PPE-would do) and simply doing nothing at all or worse trying to prevent the family from calling (this could get you in big trouble).

jdub6 · Oct 15, 2016

My mom is currently in Hospice Of Cincinnati and we were FORCED to sign DNR to be admitted and ws told Medicare WOULD NOT PAY UNLESS WE DID.........

We did not agree with basically little to no care under DNR and that hospice would not even provide like blood ect if hers got low ect ......SOME THINGS CAN BE "FIXED" and ARE NOT THAT invasive to do..

I am not going to respond to this whole post for many reasons. But for the clinical staff out there wondering about the legality of "required" DNRs i think this brings up a good point.

As far as i know it is illegal to require a DNR. However the quote above equates DNR status with blood transfusions which is totally wrong. Hospices must admit pts who have appropriate terminal prognoses and desire palliative care but simply wish to recieve CPR in the event of cardiac arrest. However, blood transfusions based on lab results is not CPR and is not immediate treatment for cardiac arrest. Say the mother referred to in the quote in referred for hospice with a terminal dx of myelodysplastic syndrome. If she wants to go home with symptom management only but isn't ready to sign a DNR she could be admitted to hospice as a full code. But if she wants to continue her weekly labs and be transfused for every abnormal value then that is aggressive treatment for her terminal disease and she is not appropriate for hospice.

Hospice pts do not give up the right to be full code. They do however give up their Medicare benefits for aggressive/ curative treatment of the terminal condition-this is what the Medicare hospice benefit election forms are for. The Medicare hospice benefit is a trade off. The pt gives up their coverage for life prolonging treatment of the terminal illness in exchange for the benefits under hospice.

Hospice is not mandatory for anyone, but if a pt does not want to stop life prolonging treatment they are not ready for hospice and admission can be refused. CPR is not the same under Medicare regs as other aggressive treatments.