CCUnocRN

We were told that Our state had always had that law, but it had been misinterpreted. The Ethics Dept and the institution says that this is the correct interpretation.

Recently our hospital system has stated that once a DNRCC order has been written (changed from a Full Code or DNRCCA), we now need to wait 48 hours before withdrawl of ventilator, vasopressors, LVAD, etc. (anything already in place, we cannot change) The entire time years that I have worked here, we have done things differently. Once the family/patient decided to change the code status to DNRCC, we ususlly began our comfort care protocol (morphine for pain/ativan for restlessness, etc) and started weaning down the vasopressors first. If their BP was only marginal with vasopressors, this was usually all that we needed to do. We had the family there in the room and provide emotional support and spiritual support.Now, once the family wants their loved one to be a DNRCC, we have to wait 48 hours before doing anything with the current life-sustaining measures. An example that happened to me recently: an elderly pt was sent from one of our outlying hospitals on the vent, neo/levo running, and with an LVAD. They arrived to our unit around 2pm and I came on duty at 7pm. They had placed the comfort care orders on the chart "except: ventilator, LVAD, neo and levo. This seems to be conflicting. The LVAD started alarming because the patient was deteriorating, and the LVAD couldn't do it's job. The physician stated to just turn down the P level on the machine. I called the rep and he stated that I could just keep turning down the P level. After I couldn't turn it down anymore, the Impella started alarming obnoxiously "Suction Alarm". I called the physician and explained that since it wasn'table to function appropriately, could I turn it off? He replied "No." I called the rep and he told me how to disable the alarms. Which I did.So, I've got life-sustaining measures that are clearly not effective to run for 48 hours, but also comfort care orders in which I am giving morphine and ativan. The patient's family also frail and elderly, were in the room. They had to listen to alarms and was also worried about respirations between the ventilator. The hospital ethics committee has stated that we have just been misinterpreting the law all of these years, and now we are following the law. I have read and reread the state code and I am not seeing where this is the case. It seems to me that if the patient had told the spouse their wishes, and the spouse says DNRCC, we should be able to comply with their wishes and begin the comfort care protocol asap including the withdrawl of ineffective life-sustaining measures. If anyone could respond with helpful info, I would greatly appreciate it. Thanks!!CCUnocRN

off-label use is the practice of prescribing drugs for a purpose outside the scope of the drug's approved label, most often concerning the drug's indication. in the united states, the food and drug administration (fda) requires numerous clinical trials to prove a drug's safety and efficacy in treating a given disease or condition. if satisfed that the drug is safe and effective, the drug's manufacturer and the fda agree on specific language describing dosage, route and other information to be included on the drug's label. more detail is included in the drug's package insert. however, once the fda approves a drug for prescription use, they do not attempt to regulate the practice of medicine and so the physician makes decisions based on her or his best judgment. it is entirely legal in the united states and in many other countries to use drugs off-label. http://en.wikipedia.org/wiki/off-label_use diprivan is approved for use in sedation, such as for ventilator compliance and in surgical procedures. it has not been specifically studied in clinical trials for the indication of seizure suppression, but physicians can use medications "in the practice of medicine" for other purposes based on "sound scientific evidence". hope that helps. there is also good information on the www.fda.gov site under the irb information sheets. thanks! ccunocrn

I have a question about using Diprivan off label for seizure suppression? I work in CCU and we had a pt that became hypotensive (sbp 50's). She was on continuous EEG monitoring, which we normally do not see in CCU, nor have we ever used Diprivan for this off label indication. I'm used to using Diprivan for sedation/vent compliance. We normally turn off the Diprivan drip and call the physician if pt becomes hypotensive. We have critical care docs that are the primary, so I called the doc on call, updated him on events/condition and told him the Diprivan had been turned off. The pt was end stage renal on dialysis, intubated, and on Levo at the time. We started an Epi drip as per order. Her sbp temporarily increased 80-90's then dropped again. Further orders from physician was fluid bolus and cardiology consult in AM (d/t brady heart rate and widening of QRS). We also did 12 lead EKG. I also had the house officer come by to update her. Pt SBP stayed 70-80's. This all happened around 3am. Family was notified, they came in and decided at 7am to change code status to DNRCCA (she had been ill for some time, having a trach/Peg tube placed last August). When the neurologist came in that morning, he was irate that Diprivan had been turned off. He stated that it should not have been turned off because it was for seizure suppression. Our medical director called me the next night because the neurologist was upset. I asked if there couldn't be a standard of care order sheet stating "Do not turn off Diprivan" so it would be communicated to all staff and placed on our Kardex. (There wasn't an order written to NOT turn off for any reason. The medical director stated "I don't think we need to go that far. If you want to add that to the Kardex, that would be up to the CNM/nursing staff to do." If we might have future patients on Diprivan for this off label use, it would be nice to do some QA now and put a process in place. My main concern was pt's B/P. (Apparently the Neurologist wanted an incident report made out d/t Diprivan being turned off). We also use the Leap Frog system where the critical care physician is on all cases in our unit (and the attending)except the pts with strictly a cardiac Dx. Has anyone had any experience with this off label use of Diprivan? Is there a standard protocol used for a higher dose Diprivan in seizure suppression?Thank you!!!

I have a question about using Diprivan off label for seizure suppression? I work in CCU and we had a pt that became hypotensive (sbp 50's). She was on continuous EEG monitoring, which we normally do not see in CCU. We normally turn off the Diprivan drip and call the physician if pt becomes hypotensive. We have critical care docs that are the primary, so I called the doc on call, updated him on events/condition and told him the Diprivan had been turned off. The pt was end stage renal on dialysis and Levo at the time. We started an Epi drip as per order. Her sbp temporarily increased 80-90's then dropped again. Further orders from physician was fluid bolus and cardiology consult in AM (d/t brady heart rate and widening of QRS). We also did 12 lead EKG. I also had the house officer come by to update her. This all happened around 3am. Family was notified, they came in and decided at 7am to change code status to DNRCCA. When the neurologist came in that morning, he was irate that Diprivan had been turned off. He stated that it should not have been turned off because it was for seizure suppression. Has anyone had any experience with this off label use of Diprivan? Thank you!!!