Pt choking and DNR....

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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?

Also, directly relating to the scenario, have you ever choked on a bit of food or drink? Compassion alone should have you doing something about it to relieve suffering. If they then code, you let them go. I don't think it matters what illness they have, whether they have dementia or not, you are bound by the documented NFR. NFR doesn't mean you let a patient suffer though. If they are dying and struggling to breathe or have pain, you still treat that.

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Specializes in Emergency.
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.

I think, BabyLady, that if you follow the course of actions you've described when responding to an emergent situation with a pt who is DNR, you can be the one to expect to have problems keeping your license.

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Specializes in Emergency.
And how many have heard 'old' nurses advise young ones that when an elderly or terminal patient codes without a not for resuscitation order just don't notice, shut the door and walk away?

I've heard it said quite a few times. I haven't seen it done.

I have heard of this only once, and it was done several years ago by a tech who still (I don't know how) works on our floor.

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This would be an interesting scenario........what if a pt with advanced dementia has an NFR (DNR) documented by the doctor. There are no relatives for him to consult with. The pt is dying but before he dies he says to the nurses 'don't let me die, save me.'

He would not be considered mentally competent to make a decision regarding his resuscitation status, or would he?

And it could happen. Have you ever seen a small window just before some patients with dementia die, and they suddenly seem rational and not so confused?

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I just remembered something about a pt with advanced dementia. She had expressive aphasia so what she said was not able to be comprehended at all.

One day she became agitated and said she was going to her funeral. She then started looking extremely scared and said 'the bangbang is coming.' I was trying to reassure her and asked what the bangbang was. She pointed down the ward. Where she pointed we had four patients dying in the last four rooms.

While trying to settle her I walked her around the ward. When we were about to reach the first of the dying patients rooms she stopped and said 'don't go through there.'

There was nothing there so I asked her what it was.

'Don't go through the door?'

I asked her why.

'The bangbang is there. The bangbang is coming.'

The patients all died that afternoon. Yet she still refused to walk past the point where her door was for a couple of weeks.

This patient usually couldn't express anything that we could understand. She didn't know what her name was.

We're not a religious bunch on my ward....just typical Aussie nurses......but working with the dying has certainly opened our minds.

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:-)

Reminds me of another pt with dementia who had expressive aphasia, but when she got angry she spoke, or yelled, perfectly clearly.

Anger was usually the result of us not letting her escape the hospital.

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Specializes in CVICU.
This would be an interesting scenario........what if a pt with advanced dementia has an NFR (DNR) documented by the doctor. There are no relatives for him to consult with. The pt is dying but before he dies he says to the nurses 'don't let me die, save me.'

He would not be considered mentally competent to make a decision regarding his resuscitation status, or would he?

And it could happen. Have you ever seen a small window just before some patients with dementia die, and they suddenly seem rational and not so confused?

I have not seen this, although I'm not saying it doesn't happen. It just hasn't happened to me. I do not believe he would be considered mentally competent to make that decision even if there was a way to prove that in that one moment he was completely rational and lucid. Although I don't know the actual legality of it, a moment (or even several moments) of lucidity is not enough to deem one competent to be allowed to make decisions.
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I've only seen it twice. The first time I was a student CNA, many years ago. The pt had advanced dementia and could be extremely aggressive. I was showering her and she said she'd always loved me washing her because I was so gentle. Then she started chatting quite normally. I returned her to her room and almost the entire staff turned up to see the sudden transformation in her. Everyone was chatting and laughing as we were witnessing a return of the person she used to be.

An hour later she was dead.

Her dying was horrific. She started struggling to breathe and was reaching out for help. The staff ignored her. It was the first dying I'd ever witnessed in my life and when the staff walked away I went over and held on to the pt, trying to reassure her. She died while I held her. I remember the staff later saying that I'd be no good as a nurse, because I was a sook. I've never forgotten that.

On my ward we are all sooks. We take it in turns having a few tears. Usually when working with a pt and their family you don't get a chance to reflect and become tearful, you're too busy tending to their needs. Anyway, it is only later, during break that we might say we'll miss a pt and tears will well up in our eyes.

When a pt is dying and they have a large family it is like taking on a multitude of extra patients because their relatives are often the ones we spend most of our time with, trying to support them through the dying as it is more common these days for people to not have experienced it before. I always think that what they witness, and your every word and action, they will never forget, because it is such an emotionally charged time for them. And it is a huge responsibility to get it right, because what they witness will probably play a huge part in how they approach their own dying. We joke that we wish there was a gaseous form of diazepam we could put through into the relatives room, because they are the ones who suffer, frequently more often than the patient.

Students always ask me how I know what to say. I tell them that usually, if it comes from the heart you can't get it wrong. And, most of the time you don't need to say anything. They just want someone to be there. You reassure with your presence. We are like the captain of the plane, they just want to know someone is steering things.

To me it is better to experience those moments then to bury everything, or to put up a wall and refuse to feel. Sometimes I've had tears in my eyes and the response of the family has been to say that it makes it easier for them when they know the nurse looking after their loved one really does care.

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Specializes in Hem/Onc, LTC, AL, Homecare, Mgmt, Psych.

911 needs to be called-- All because the pt is DNR does not mean we don't treat an emergent situation. Go to your state dept of health and search for "dnr and choking" it should bring up some previous investigations or reports on places for that.

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Specializes in Med/Surg, Psych.

unsuccessful heimlich that results in a code is still a code, regardless of what precipitated it. say for instance the EMT's arrive and they see no pulse, no respirations and a big fat DNR. you say "but the patient had choked!" they are not going to break out the paddles at that point.... yes, try your hardest to remove the airway obstruction but a code is a code. heart stops, hands off.

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Specializes in LTC, ER, ICU, Psych, Med-surg...etc....

It is true that an unsuccessful heimlich will result in a "code" however, a "code" can't be done because you will have a blocked airway and no air exchange. You must still continue to heimlich the person even though they are unresponsive and "down" when the EMS arrives they should try to remove the obstruction because they have laryngoscopes and could possibly do this. I am concerned about the legal ramifications of this because it began as choking- not an arrest situation. I can hear it now..."They let my momma choke to death..." However....on the flip side of that, should you have a severely demented resident who is at risk for such a thing, then a meeting/care plan should be done regarding this a well as a discussion with the family being specific as to "what to do if momma chokes and the heimlich is not effective"...this should be well documented. Many times advanced dementia predisposes to inability/forgetting how to swallow. Choking can happen to anyone, you, me or an 88 year old demented person, but...a DNR does not mean that if I choke you do not try to help. It's not the ones on the aspiration precautions that are the scary ones...it's the ones who are not! Familarize yourself with your facility policy on this.

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Why aren't we reacting? We are stopping to read a most form? If I'm choking, please don't go find my chart before dislodging the food!

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