"Limited Resuscitation"

Pediatric Critical Care Columnist · Jul 22, 2006

This certainly seems to be a hot button. :flamesonb

While it's true that most lay people really don't understand the process of resuscitation, our responsibility is to follow the patient's wishes. Whatever those are.

Working in pediatrics, we take our direction from the parents. This can cause a great deal of distress to the staff caring for the child, because many times the parent is not ready to let go, but the child is clearly beyond saving. Our doctors have found somewhat of a compromise that, while not perfect, does allow for some level of comfort for all concerned. The chart may say, "DNR" on it, but there are caveats, usually "no compressions, no push vasoactive drugs, no defibrillation" or some other combination of treatments to be avoided. We will do everything short of whatever has been decided to be omitted, including fluid boluses, escalating vasoactive infusions already running, and escalation of ventilation strategies. Sometimes we nurses view it all as bordering on torture, but that's what the parents want.

ICURN_NC · Jul 22, 2006

This "al carte" DNR menu has been an issue in our unit for the last few years.

I had a pt the other day who had this order: "DNR- no chest compressions, no chem code, no defib- but OK to use pressors." Isn't that a type of chem code, since we are using drugs to keep him alive? :smackingf I truly don't know, it seems like a contradiction.

So this guy bradys with sxn sometimes, what happens if he doesn't recover? Do we not give him epi, but start some dopamine because that's ok?

I do support the rights of pts to make their own decisions, especially DNR's, I'm just scared I'm going to do too much/not enough based on these "menu items" and it'll come back to bite me.

PS I understand the irony of my little signature there. ha!

Antikigirl, ASN, RN · Jul 23, 2006

We no longer have orders for 'limited intervention'...in fact, if it is ordered we have to call the MD and have them meet with the pt again to fill out the proper forms to know exactly what the pt means and wishes! If I see limited interventions on a order with no parameters it is like an order that doesn't have dosage or route..and it ignored and the pt is full code (the parameters have to be in ALL orders!!!!).

This is because it is too vague...limited is different for everyone, especially pts or their families! Some people say no compression, shock twice, and no meds...ummmmm okay not going to do jack but okay...others say No compressions, PO meds, and shock..again..huh? It is just too odd, and it shows that the pt is not informed and can not be held to an order without "informed consent for Tx".

I would most certainly take the time to ask an MD what they mean if they order that, and have them order the parameters!!!!

Indy, LPN, LVN · Jul 23, 2006

It bothers me that we typically don't send a DNR in our hospital to the ICU, because, well, what's the point? Okay, let me rephrase that. I understand why we keep them on telemetry, but it bothers me when my DNR patient (with history of COPD) has a heart attack and is allergic to morphine. And is alert and oriented, and knows what's happening, and it takes me twenty minutes to talk her into taking NTG SL!

I thought about doing an EKG, but we weren't going to treat it... so nevermind. Called her family, called the on-call for her doctor. Wound up giving ativan and letting her sleep. Next day her doc determined that she got morphine in childbirth 40-odd years ago and it made her itch. So she got a lot of morphine for the rest of the day, as much as it took to make her comfortable, kept on having her massive MI and died that evening.

It was utterly frustrating to care for this lady. I wanted to call the rapid response team, who would, if she weren't a DNR, have intubated her and whisked her away to ICU and kept her alive a while. That would have felt like I was doing something! Instead, I had to sit there and listen to her life story and hold her hand. She really didn't want to stop talking, while having chest pain so bad that it made her cry and breathing 30+ times a minute. It's so hard to watch people actively suffer.

The latest case we got of "limited" was this adorable LOL who was in the hospital for syncope, DNR "with treatment of symptomatic bradycardia please." Okay. Well she wound up getting a pacemaker so I guess they treated it! It seemed to me the patient wanted the main problem addressed, but had a healthy fear of CPR. Given her size - tiny - and her age - 80's- I could understand that. We would have had to have another conversation or two, with the physician and family involved, if she had not been a candidate for a pacemaker.

My first dying patient was on a dobutamine drip the day they made him a DNR after talking with his granddaughter (only living relative) and did they DC the drip? Well no. Then they put parameters on his morphine! Don't give if the SBP is below 80 and somesuch crap. Urine output was nil. They'd left him on NS for several days before this and it was showing up as gargley breathing. Fluids still going. Blood pressure in the 70's and thready. Neuro status in the toilet, as in, he could moan and holler but had sluggish pupils. I called the doc and got the morphine orders changed to something more approaching comfort care, and asked for the dobutamine drip to be DC'ed. HA! This is what he said: "No, let's leave that going in case a miracle happens." I thought, considering his pain and his condition, the miracle will be when he dies! It was another 24 hours before he did.

I've never seen a chemical code. I try, whenever possible, to educate the family and the patient. It takes a lot of conversations sometimes. The more unable they are to let go, the less they listen. A lot of people think a vent is a death sentence. Or that morphine at the end of life is a mercy killing. People have all sorts of myths based on lack of knowledge and if it's those myths that they are basing decisions on, it's our job to make sure that their decisions are informed, even if the information is something they don't like or have a hard time accepting.

rninme · Jul 23, 2006

Hello...back again!

At our facility a DNR is just that do not resuscitate....it does not mean Do Not Treat...and yes, DNR's end up in ICU with me. We treat their symptoms....dehydration = fluids, low spo2 or po2 = oxygen, etc. We don't code them if they arrest, but we do treat them.

Have been out in the barn looking for notes from a ethics symposium that I attended a couple of years ago. Limited code status was a big issue....and I am trying to find the info I have on it...for those on here who keep saying that limited codes are unethical. I'll keep looking....

OR2ER, BSN, RN · Jul 23, 2006

hello...back again!
at our facility a dnr is just that do not resuscitate....it does not mean do not treat...and yes, dnr's end up in icu with me. we treat their symptoms....dehydration = fluids, low spo2 or po2 = oxygen, etc. we don't code them if they arrest, but we do treat them.
my sentiments exactly..we were just talking about this the other night.our doctors usually explains everything to pt's relatives or whoever has the poa. one doctor usually puts order like..dnr/no cpr/no icu admission/no intubation/no chemical code...and usually works.
when i was new in resuscitation area of emerg..i used to ask my charge nurse why put a dnr patient who has a low blood pressure in observation area(with cm) if u need to put him/her in the resuscitation/trauma area..she just said.."well ..the pt. is dnr"..so i went to my educator and asked the same thing and got a different answer..pt should be in resuscitation area..i said why?.."well..if that patient came in with massive bleeding or choking incident..would you not treat him/her?.."..hmmm
point taken.
we do transfer pts in icu..(i just had one 5 nights ago)..and the nurse was kinda ...and says..uggh..art line,central line..etc..oh well..
next of kin should always be informed about these dnr orders.

Antikigirl, ASN, RN · Jul 23, 2006

In the case of family...this gets kinda odd and grey. If the pt is able to speak, I go by them even if they change their status. Family however is difficult and gets complicated.

With family I will only listen to the POA or spouse! AND IF they do not have a written order for DNR, I still have to treat since an MD did not sign the order!!! This protects the patient from family or spouses that might have their own best interests in mind, or doesn't understand the rules and pt wishes!

If I am not rescusitating, and a spouse or POA says to...I must (just not the other way around). Even with a DNR order in my hand. The pts legal medical rep can overseed a DNR order only in the life saving capacity. I have had this once with a wife of a pt...he was pulseless and apnec, and the wife begged us to do something..quick discussion of it..and we got 9-11 on the way and saved him...which was a good thing at the time and he saw the birth of his first grandchild a week later, then passed away a week after that. He was thankful and thanked me up and down for listening to his wife...he felt that the DNR order had to be signed in order to live at the facility, and really didn't want to be full DNR...poor guy, and good think I was there and know our state rules.