Pt choking and DNR....

[Beachbum2010]

Curious to hear opinions on this scenario...

Long term dementia patient. DNR in place. Patient chokes. Heimlich initially unsuccessful and pt codes. What should be done for this patient?

[jossjjojo]

Full Code.The choking is unrelated to the illness that the DNR was issued for.

It doesn't matter what causes a cardiac or respiratory arrest, the DNR is valid and should be honored.

[JulieCVICURN, BSN, RN]

Full Code.

The choking is unrelated to the illness that the DNR was issued for.

This very question was not only a test question in an ethics chapter but it was also in Saunders when I studied for my NCLEX.

DNR's generally do not apply in the operating room either.

Interesting. We just had this discussion in my ethics class and the opposite conclusion was considered correct. While the patient has a pulse, you continue to try to correct the choking situation, but once arrest happens you don't code.

In our facility DNR's are rescinded for 24 hours post surgery (and during procedures, of course).

[netglow, ASN, RN]

DNR stands. It MIGHT be recinded for treatment/surgery, but CAN BE maintained in surgery.

[carolmaccas66, BSN, RN]

DNR is exactly that. Treating them means ur assaulting this patient's body.

U can't legally go against their wishes. U will lose ur license & get taken to court for assault. I know it seems harsh but that is the patient's wishes & we have to follow the law.

Info from my law book.

[carolmaccas66, BSN, RN]

I've never heard of DNRs being lifted for surgry, DNR in Aust is valid for everything. Even when patients get transported via ambulance, the ambos take a copy of the DNR order with them, so the aren't liable if the patient codes and can't be sued. They WILL NOT transport the patient without the order either.

Diff laws may apply to diff countries.

ADD: well in my law book it says doesn't matter what causes the code, you still follow DNR.

Interesting discussion

[elkpark]

DNR is exactly that. Treating them means ur assaulting this patient's body.

U can't legally go against their wishes. U will lose ur license & get taken to court for assault. I know it seems harsh but that is the patient's wishes & we have to follow the law.

Info from my law book.

As others have already mentioned, DNR means do not resuscitate, not do not treat. If a DNR status meant we weren't going to do anything for a person, why would that person even be in a hospital, LTC, or hospice, instead of just at home with no assistance?

My understanding (like others here) has always been that, in the presence of a DNR order (and absent any other instructions), you treat acute problems or illnesses up to the point that a person codes, and then you don't resuscitate them. Of course, individuals who are alert and competent (or their next of kin/POAs if they are not alert and competent) have the right to refuse any treatment they wish, and expect to have that wish respected, but a DNR order is certainly not a blanket refusal of all treatment.

[netglow, ASN, RN]

Also, if you read up on hospice, there is clarity to this. But, hospice can flex as well. As mentioned you can have hospice and no DNR. And, you can keep DNR during surgery.

"Full Code.

The choking is unrelated to the illness that the DNR was issued for." -Babylady

Close, but not quite. There is not a determination in relation to the hospice dx in the above example. You have a DNR, you would intervene when someone chokes regardless of hospice/DNR. If while you are intervening r/t choking, the patient codes, the DNR goes into effect. You will not resus.

If the patient has end COPD or CHF as hospice dx with DNR, and is choking r/t secretions that are an exacerbation of Hospice dx, then you would intervene palliatively, and this scenario might end up in the actual death. The DNR stands. However if patient/family decides they want urgent care, hospice can be revoked DNR as well, and patient can emergently receive care in-patient. Horrible emotional see-saw, usually means intubation.

If the patient does not have a DNR, and is hospice and the patient chokes, aspirates, codes. This is a full code. But I can confuse it further, if they have directives that say "I don't want to be intubated" if that becomes necessary, then that is the STOP sign for intervention, and might end up in the actual death.

A patient who gets some kind of illness that is not normal progession/consequence of their hospice dx, they can receive tx for this. Usually once inpatient in hospital, hospice is revoked till discharge, then they can readmit for hospice. It's about who is getting paid/qualifying for hospice that plays here.

Hope I have not mis-stated, or confused. I gotta go to bed, am tired.

[carolmaccas66, BSN, RN]

I had this almost happen to me once, it was scary. I keep doing the bed Heimlich, to little success. And just when it was looking like we were either going to have to switch to CPR or stop PEWY a piece of scrambled eggs shots out and we hear a big recovery breathe.

It was too damn scary. Can you believe the patient wanted me to start feeding him almost immediately after and then was complaining I was going to slow?

The morale of the story is don't feed your patients too fast no matter what they say.

I had this happen to me once. I kept telling this older lady (who wasn't demented) slow down when ur eating, u could choke. Of course in the next few minutes she did choke, then afterwards tried to blame it on some coconut in her dessert. She said it was the scariest thing that had happened to her. Mind u she'd had these episodes at home when eating tinned, soft food - and of course, had never had it investigated! I told her when she was discharged to see someone but she probably never did. And yes I believe ur patient started complaining about everything. Did he say thank u at all?

I sometimes why as nurses we bother telling anybody anything, because they just don't listen.

[carolmaccas66, BSN, RN]

As others have already mentioned, DNR means do not resuscitate, not do not treat. If a DNR status meant we weren't going to do anything for a person, why would that person even be in a hospital, LTC, or hospice, instead of just at home with no assistance?

My understanding (like others here) has always been that, in the presence of a DNR order (and absent any other instructions), you treat acute problems or illnesses up to the point that a person codes, and then you don't resuscitate them. Of course, individuals who are alert and competent (or their next of kin/POAs if they are not alert and competent) have the right to refuse any treatment they wish, and expect to have that wish respected, but a DNR order is certainly not a blanket refusal of all treatment.

No, no, no. I don't mean don't treat the choking or anything like that. I didn't say that.

I said if they code we can't treat them.

Clear or not? Is it different in ur country?

[elkpark]

No, no, no. I don't mean don't treat the choking or anything like that. I didn't say that.

I said if they code we can't treat them.

Clear or not? Is it different in ur country?

You did say "treating them means (you're) assaulting this patient's body," and didn't specify that you were referring only to coding someone. I misunderstood what you meant the first time -- thank you for clarifying.

[Bruce_Wayne, ASN, RN]

What is the bed heimlich?

I guess it's properly called an "abdominal thrust"

[nerdtonurse?, BSN, RN]

Put on a lawyer hat for a second...

"Nurse, did you initiate CPR on this patient or not?"

"Yes, but they were choking."

"Did you know the patient was a DNR?"

"Yes, but they were choking."

"And knowing the patient was a DNR, you performed CPR anyway?"

"Yes but they were choking."

"Did the patient have a rider in their DNR that said, 'DNR unless pt choking?'"

"No, but..."

"So, knowing the patient had a valid DNR, signed by a MD, you took it upon yourself to initiated a Code Blue on the patient without consent? Gave meds essentially without a MD order since the patient had a valid order specifically stating the patient NOT be coded and receive those meds...? So you not only coded a no code patient, which is battery, but you have meds with no order, so you practiced medicine without a license..."

I'm breaking out in a sweat just typing this up. A lawyer would eat you up in court. So, no, I'd Hemlich the patient if they choked, and I'd be really clear to anyone else in the room who saw me doing abdominal thrusts (the "bed Hemlich") that I wasn't doing cardiac massage, but abdominal thrusts. And if they lost their pulse (since they'd already stopped breathing, I guess), then I'd stop.