Well, what I've long suspected about the hospital in the town where I work is, in fact, true: DNR indeed does mean "Do Not Treat". The EMTs won't even transport someone to the ER if their advanced directive says "comfort measures only", even if they're in obvious DIScomfort. Why? Because some group of high-ranking muckety-mucks has decided that treating the sick is not a 'cost-effective' use of the hospital's services.:angryfire
I couldn't believe it when I read about this in the newspaper. Then I actually heard about it again from the paramedics I called today for a resident who was having severe back pain from an unknown cause. They were very sympathetic, but they told me the order had come down NOT to transport anyone to the ER unless they were, essentially, a full code and had one foot already in the grave. In other words, if a patient is elderly and/or has a DNR order, the hospital won't even 'treat 'em and street 'em' anymore. They won't even LOOK at them.
I am so angry right now I could spit nails. Naturally, I don't believe in using the ER as a primary care provider, but for crying out loud, when one of my residents is desperately ill or in pain and I don't know why---and their PCP isn't responsive to their needs---where else are we supposed to turn for help? And God help you if you're over 65 and on Medicaid.......you can't use the ER, but you also won't be able to find a PCP willing to take you anymore.
The thing that really burns me up is the fact that our Greatest Generation paid into the "system" literally for DECADES, and now when they need help, it's not there for them. In fact, the healthcare conglomerate here in our area treats them like parasites. Unfortunately, the organization is a monopoly, so it's the only game in town. And now it's turned every standard of decency I can think of on its ear: you're welcome to use the ER if you have private insurance and/or are young and 'productive', but if you're elderly, frail, and/or poor, the hell with you.
Yep, this really makes me look forward to old age..........when my body starts failing, I think I'll just walk way, way out into the wilderness and let nature do what it will, as our ancestors used to do when they sensed that their time was near. It beats the heck out of begging for some small share of mercy and being treated like a "useless eater", as one Adolf Hitler used to put it.:angryfire
"Durable Do Not Resuscitate Orders shall not authorize the withholding of other medical interventions, such as intravenous fluids, oxygen or other therapies deemed necessary to provide comfort care or to alleviate pain."
I think you should contact your state Ombudsman and EMS regulatory agency.
I love a previous posters statement about,"wait till it happens to them". Isn't that the truth? These decision-makers of these outrageous policies must be living in glass houses. But we'll be waiting for them and say sorry, bye bye!
Specializes in LTC, assisted living, med-surg, psych.
Update: I did manage to get a doctor's appointment for the lady after the EMTs called him on the phone and told him what the problem was. She had just been to see him the day before, and when he asked her about her pain, she---typical of her generation---said "Oh, I'm fine". He had prescribed one, count 'em, ONE extra-strength Tylenol Q 6 hrs prn pain and declined to give her anything else because "she said she was OK". I don't even remember the number of times I have faxed this MD with requests for PRNs for his patients in my facility, only to end up with orders like this one.
Good grief, anyone could've figured out this woman was in pain just by the tension in her voice and the obvious fact that she winced everytime she changed positions.....but no, we give her one lousy Tylenol and call that adequate pain relief.
So he finally gave her an Rx for Tylenol #3 after considerable pressure from both the resident's daughter and myself. I'm OK with that, even though I wish we all hadn't had to go through this nonsense to get from point A to point B. But I am NOT OK with being unable to send my residents to the ER when I feel they need a medical evaluation, for pain or anything else. The "comfort measures only" statement on the advanced directive (POLST) form specifically states transport to hospital only if comfort care cannot be achieved in the home or LTC setting. Nowhere does it say "Your local ER will tell the ambulance to turn right around and take you back home without being seen.":devil::angryfire:madface:
.....one nursing home advocate i was in contact with actually heard the elderly being refered to as "useless feeders,"
i have heard nursing home patients called that and worse. only a true sociopath could talk about other humans this way. i wish sociopaths who make their money off these useless feeders and who are potential useless eaters themselves would be jerked up by the collar and taken to a mirror where they could see what useless is. i hope one day they say it within earshot of the wrong person.:angryfire:angryfire:angryfire
Well, what I've long suspected about the hospital in the town where I work is, in fact, true: DNR indeed does mean "Do Not Treat". The EMTs won't even transport someone to the ER if their advanced directive says "comfort measures only", even if they're in obvious DIScomfort. Why? Because some group of high-ranking muckety-mucks has decided that treating the sick is not a 'cost-effective' use of the hospital's services.:angryfire
Of course - Comfort Measures MEAN that in the event that an individual on these measures decompensates they will be placed on hospice and end of life care, making them comfortable and treating their symptoms as they expire from this world. What are you going to do in the ER differently from what a nursing home or a subacute rehabillitation facility could accomplish? answer ---> NOTHING.
I couldn't believe it when I read about this in the newspaper. Then I actually heard about it again from the paramedics I called today for a resident who was having severe back pain from an unknown cause. They were very sympathetic, but they told me the order had come down NOT to transport anyone to the ER unless they were, essentially, a full code and had one foot already in the grave. In other words, if a patient is elderly and/or has a DNR order, the hospital won't even 'treat 'em and street 'em' anymore. They won't even LOOK at them.
DNR/Do Not Resucitate does not neccesarily mean that the same individual is on comfort measures, BUT if you are on comfort measures you are of course on DNR. DNR patients who are not on comfort measures only recieve full medical treatment and I can assure you that if you call any ER in this country they will accept a DNR patient. I am not sure where are you getting these facts from?
I am so angry right now I could spit nails. Naturally, I don't believe in using the ER as a primary fundamental, i.e. its not rocket science.
care provider, but for crying out loud, when one of my residents is desperately ill or in pain and I don't know why---and their PCP isn't responsive to their needs---where else are we supposed to turn for help? And God help you if you're over 65 and on Medicaid.......you can't use the ER, but you also won't be able to find a PCP willing to take you anymore.
What?? Now I am really confused - are you talking about a DNR comfort measure???? We should respect the patient's and the patient's families wishes.
Yep, this really makes me look forward to old age..........when my body starts failing, I think I'll just walk way, way out into the wilderness and let nature do what it will, as our ancestors used to do when they sensed that their time was near. It beats the heck out of begging for some small share of mercy and being treated like a "useless eater", as one Adolf Hitler used to put it.:angryfire
It's times like these we have to sit back and look at the data and factual information around an issue and try to avoid becoming overly emotional - only at this time can we be objective and deliver the best care possible
Specializes in LTC, assisted living, med-surg, psych.
The facts came right out of the hospital CEO's mouth, and out of the mouths of the paramedics I spoke with Friday. I sure as heck didn't pull them out of thin air!
Of COURSE I understand about DNR orders. I have one myself, with limited interventions for conditions such as pneumonia (or anything else that can be cleared up with a short course of ABX). But for mercy's sake, if I'm in severe pain and my doctor isn't available, I ought to be able to go to the ER, be evaluated, and obtain some relief. And so should my 97-year-old resident.
I am sure this will anger some people, but I refuse to be a DNR or to allow that for anyone I have a choice about. I have seen too much. When health care personnel understand what "DNR" means, then I would reconsider. And by the way, the world is full of certain types of young people who are as much "useless eaters" as any of the elderly.
when a ltc employee speaks up for a resident they are considered to be 'trying to protect their job'
i know that mds are tired at the end of a day and they are called but this is their job, they collect money from medicare/medicaid with the understanding that they are going to provide good or at least adequate care
I agree that if ER care is needed there should be no hesitation, and people should be entitled to emergent care no matter their DNR status, age or whatever. But what comfort measures are we talking about that only the ER can give. I can think of some like paracentesis, or an epidural. what others are there that I'm not thinking of? The ones I mention above are usually done by appointment.
There's also the situation where the attending doc is unresponsive to requests, and sometimes the ER doc can push for what the patient needs.
The facts came right out of the hospital CEO's mouth, and out of the mouths of the paramedics I spoke with Friday. I sure as heck didn't pull them out of thin air!
The fact is if someone is on DNR w/ comfort measures they are DYING and they attempts should be made to make the DYING process as comfortable as possible. You bring someone to the ER in order to save their life or prevent morbidity, it makes no sense to bring someone who knows full well that they are dying, has accepted the fact that they are dying, whose physician knows full well that they are dying, to the emergency room in order to make them more "comfortable" in dying. Bringing someone on comfort measures to the ER is completely illogical and in my opinion, an emotional reaction devoid of pragmatism.
Of COURSE I understand about DNR orders. I have one myself, with limited interventions for conditions such as pneumonia (or anything else that can be cleared up with a short course of ABX). But for mercy's sake, if I'm in severe pain and my doctor isn't available, I ought to be able to go to the ER, be evaluated, and obtain some relief. And so should my 97-year-old resident.
If the scenario is as you described initially, i.e., you are DNR and are on comfort measures and you are 97 years old and chronically ill with multisystem disease accompanied with pain - as a nurse you would call the physician and the physician would evaluate the patient WHO IS ON COMFORT MEASURES and determine how to make the patients DYING PROCESS more comfortable. In most cases this means utilizing more pain medication to assist in the DYING process. If you disagree with this you must be assuming that those evil physicians are incompetent and do not know what the hell they are doing and or do not care about the patient.
It seems completely ridiculous, in my mind, to take a 97 year old guy with multisystem failure who is in pain, DNR and on comfort measures and rush the guy to the ER so that the ER doc can be the one to give him the morphine sulfate rather than the attending - MAKES NO SENSE - as I said before it sounds like an entirely emotional outburst and doesnt take into consideration being rational about the reality of the situation. As nurses we should realize that the process of dying is often accompanied by pain and even if you evaluate the pain by 10 different physicians the patient is going to be given a narcotic like morphine sulfate anyway. I was surprised to read some of the posts to this thread - "Call the press etc" I mean completely ridiculous IMO and i cant believe that some of these people are nurses who should know full well what DNR/comfort measures mean......
Once again, i am merely stating my opinion and anyone and everyone is free to disagree with it but I appreciate being able to express it -
Naturally, I don't believe in using the ER as a primary care provider, but for crying out loud, when one of my residents is desperately ill or in pain and I don't know why---and their PCP isn't responsive to their needs---where else are we supposed to turn for help? And God help you if you're over 65 and on Medicaid.......you can't use the ER, but you also won't be able to find a PCP willing to take you anymore. 
MichaelFloridaRN
109 Posts
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