Pt choking and DNR....

Specialties Geriatric

Published

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?

I've seen a DNR coded before because the family comes out shouting that they've changed their minds. I wonder how common that is, would it be ok to start a thread asking this question?

Up Vote Up Vote ×

Basic first aid and honor the pt's DNR.

Up Vote Up Vote ×
Specializes in Critical Care.

For whatever reason, DNR has become a catch-all term for everything we do when a patient is circling the drain. Maybe it's because we use the term "resuscitate" for things other than CPR, such as fluid resuscitation.

But really, the "R" in DNR is the same "R" as in CPR. DNR refers only to actions associated with a sustained cardiac and/or respiratory arrest, not intubation, not meds, and definately not abdominal thrusts for a foreign obstruction in a pt who still has a pulse. DNR typically does not preclude airway suctioning either.

Up Vote Up Vote ×
Specializes in Peds Medical Floor.
If the patient codes for whatever reason and they are a DNR then do not resuscitate. I would do the heimlich, suction, whatever I could but once they "code" it's time to stop treatment.

This actually happened at my facility a few months ago and this is what we did. Once the resident stopped breathing and didn't have a pulse the nurse stopped all treatment. She was suctioned and the Heimlich was performed, but no CPR. It was horrible. Her family was there and had been feeding her when she choked. Poor people. :crying2:

Up Vote Up Vote ×
Specializes in Cardiology.
but a DNR order is certainly not a blanket refusal of all treatment.

It is when there is no pulse or respirations.

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.

Exactly

Up Vote Up Vote ×
Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

I used to work in palliative care. Many people there were for treatment of their condition, then they might go home for a bit, so they'd be in & out the hospital. Many were DNR. It was so awful watching them slip away, but the families used to be relieved afterwards and probably the patient was relieved too.

But this is what the patient/family want, so we must stand by their wants and by what the law says.

Have u ever seen a young Dr doing CPR, pounding on a 92 year old woman's chest, who verbally (not written) said she didn't want to be revived? Cos I watched this in horror one day & heard her ribs cracking. There was a nurse practically screaming at him that this woman had verbally said she didn't want any life saving measures if she coded. It was absolute bedlam, and it was so terrible to watch. She wasn't my patient so I don't know why she hadn't signed a DNR order. She should have been allowed to just slip away, and kept her dignity and peacefulness. I still get teary thinking about that lovely lady.

I think we automatically want to save everyone - it's our instinct - but I myself am always, ALWAYS thinking of the law, because I have known nurses who have been ripped apart by lawyers due to indiscrepencies & some told me it was the most harrowing experience of their lives that they wouldn't want anyone to go through.

Up Vote Up Vote ×
What do you consider to be keeping someone "comfortable" when s/he is choking? Choking is certainly not comfortable.

That was the point. Try to alleviate the choking but if/when cardiac arrest occurs - do nothing.

The notion made by others that a DNR is only valid if arrest is made in relation to the existing disease process only is a load of BS. I have yet to see a DNR order that reads "DNR if (insert scenarios) but no DNR if (insert scenarios)." A valid DNR order is just that... in the case of cardiac/respiratory arrest = NO RESUS.

Our advance directives are tri-levelled:

Full Code - means meds, intubation, CPR, pull out all the stops.

DNR - transfer to ICU - means meds, intubation, etc but no CPR.

DNR - no transfer to ICU - means no meds, no intubation, no CPR, no nothing.

Up Vote Up Vote ×

I am interested to hear the opinions of some adon's and don's please. This is a hypothetical situation, not something that has happened.

Thanks!

Up Vote Up Vote ×
Specializes in NICU, Post-partum.
It doesn't matter what causes a cardiac or respiratory arrest, the DNR is valid and should be honored.

If you follow that, then expect to lose your nursing license.

......and call the Saunders publishers and tell them they are wrong while you are at it.

Up Vote Up Vote ×
Specializes in NICU, Post-partum.
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.

GOOD LORD!

I was answering a question regarding CHOKING ON FOOD!

Hospice was not even part of the discussion!

Up Vote Up Vote ×
Specializes in NICU, Post-partum.
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.

...and that is when I would answer:

"Mr. Smith signed a DNR because he had terminal liver cancer but was alert and oriented x 3 until he swallowed a piece of bread that was lodged in his trachea and he turned blue. Mr. Smith signed the DNR WITH THE UNDERSTANDING that it would be cancer-related complications leading to his death...he never signed the DNR believing he was going to slowly aphyxiatiate to death from eating which can take as long as 3 to 4 minutes which causes an insurrmountable amount of suffering which is INCONSISTENT with how liver-cancer patients usually die. Therefore, I full stand behind my decision to fully code this man who was NOT ready to die from the illness FOR WHICH THE DNR WAS SIGNED."

Up Vote Up Vote ×
Specializes in NICU, Post-partum.

Side point and then I will be quiet on this subject:

This is EXACTLY why I would never, ever sign a blanket DNR in a hospital....ever.

Too many healthcare professions, both physicians and nurses, have their own interpretation of what a DNR is and when it is to be followed vs not.

That is when you need to have a medical power of attorney assigned to someone in the event you are incapacitated and these can be drawn up in advance...that way, you can discuss with that individual, what you want and how you want it and under what circumstances because a DNR is more complicated than that.

Up Vote Up Vote ×
+ Add a Comment