Transfering DNR pts to MSICU

[Lorie P.]

:stonehere goes, we have this one md that will constantly send pts that are dnr's to the unit. he comes in makes rounds, sees the pt's bp is low, wants a dopumine drip, which we can't do on the med/surg floor then writes orders to transfer to the unit.

mind you these pts are usually 80+ with x medical problems, so he orders labs, blood, iv fluids, xrays, the whole nine yards. so then when we call the unit to give report and tell them pt's code is dnr we catch all kinds of hell.

no one ever says anything to this doc, the pts go to the unit and usually end up expiring there.

now last night he sent 4 dnr's to the unit and filled the last 4 beds, was talking to one of the unit nurses who was peed off cause 3 pts were kept in ed cause of no unit beds. 1 pt had k+ level 8.0 and inverted t waves, another was a cva with active cerebral bleeding and the 3rd was a young man that got stabbed in the heart with a knife during a fight.

just needed to vent! it makes no sence to me. yes, i understand what dnr means, but why can't we just keep this doc's pt clean, dry and comfortable?

any comments?

[TigerGalLE, BSN, RN]

Well just because a patient doesn't want CPR doesn't mean they don't deserve treatment. You can do many things to treat a patient without CPR and intubation. If a patient needs a drip I don't see a problem with them being transferred to receive the care that they want and deserve.

My biggest pet peeve is when I have a patient who is a cat 3, meaning no intubation no CPR. When they start to crash and I need help treating them.. Everyone says oh they are a cat 3, and walks away or says don't worry about it. I'm sorry but this is a patient who wants to live, they just don't want CPR or intubation. We need to do everything we can to treat the pt, even if that means BiPap (if okay with the pt and family). They have a right to live just like everyone else.

Just my 2 cents

Tiger

[mianders, RN]

Just because a patient is a DNR does not mean you don't treat them. If they have a medical problem you still have to try and resolve the problem. If they had pneumonia would you deny them antibiotics? If there BP is low would you deny them a medication, even if they had to go to the unit to get it? They are not dead yet!

[TigerGalLE, BSN, RN]

Now if it it a Cat 5 patient. that is different. Cat 5 means all treatment is stopped. Only comfort care is provide. Now no one should send them to the unit. If all the patient/family wants is comfort care then the pt stays on the floor and is referred to inpatient hospice. Sometimes transferred to a hospice house.

Tiger

Is this doc sending Cat 3 patients to the unit or hospice patients to the unit?

[DayOhioRn]

Here is my ,

If a patient is a DNR-CC, COMFORT care only...DRIPS of any kind are indeed Extraordinary measures.

Case in point, I had a DNR-CC with low pressures and a decreasing RR and increased HR. Family wanted NO extraordinary measures and the Doc wanted ICU. I refused to transfer this patient to a overcrowded ICU or CICU to take up a bed during BUSY trauma weekend ( We are a LEVEL 1 Trauma Center who CANNOT reroute when everyone else has) . We had 4 intubated FULL CODE patients waiting in ER for hours for an ICU bed. They indeed had priority. Why transfer her to ICU when, as a Advanced Care floor, we could weither place her on a low dose pressor and bipap or let her peacefully go without suffering as her and her family wished. The outcome? She was placed on a low dose pressor we could manage and bipap ( which broke down her face over the course of the 3 weeks she was left on it. The kicker......the DOC CHANGED her to a CHEM CODE to do it, dispite the family's uncertainty about changing the code status. She used the family's uncertainty to change the Code Status. She survived and went to an ECF Tuesday after 3 weeks with us. She is no longer coherant, but she is alive.

There are many levels of DNR. The worst is the famous Chem code, "nothing but the drugs". I often have wondered WHY this is an option since if I can't intubate you, or do chest compressions just HOW are those drugs going to magically save you from Cardiac or Respiratory arrest? I have sent many of these to ICU since we can start drugs on them, but many, many of these patients DIE.

DNR ARREST should also go to the unit, after all you are doing everything BEFORE the arrest occurs, and stopping only if you couldn't prevent it.

Anything less than a DNR-CC should go to a ICU or Advanced Care unit to manage vents, drips, post -arrest ect.

Comfort Care patients should NOT tie up an ICU bed because ICU is an EXTRAORDINARY Measure. However, they should be on a floor that is comfortable with managing drips and medications that will keep them comfortable, and treat symptoms.

Remember many DNR-CC patients have multiple system problems. If it is a fixable problem fix it, but if the problem is terminal....let them die with dignity and peace!

PEACE!:heartbeat

[barefootlady, ADN, RN]

DNR does not mean do not treat.

[aeauooo]

I used to work in an ICU in which the charge nurse interpretted "DNR" as 'withdraw care.' A doc would write a DNR order and this charge nurse would extubate the patient, shut off drips, d/c fluids, and let the patient die.

Oh yes, I argued with this person, who was convinced that this was the correct and only meaning of DNR.

I don't work there any more.

[RNperdiem, RN]

The deciding needs to go on between the doctor and the patients' families. "Clean, dry and comfortable" is not a unilateral decision made by the doctor.

To me, DNR means to treat the patient like any other, and only let them die once.

[oramar]

:stone so then when we call the unit to give report and tell them pt's code is dnr we catch all kinds of hell.

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i feel bad that you are the one catching the hell about this. the nurses in the unit should realize that this is out of your hands and not take it out on you. to "give you all kinds of hell" is a type of lateral violence.

[miko014]

Here is my ,

If a patient is a DNR-CC, COMFORT care only...DRIPS of any kind are indeed Extraordinary measures.

Case in point, I had a DNR-CC with low pressures and a decreasing RR and increased HR. Family wanted NO extraordinary measures and the Doc wanted ICU. I refused to transfer this patient to a overcrowded ICU or CICU to take up a bed during BUSY trauma weekend ( We are a LEVEL 1 Trauma Center who CANNOT reroute when everyone else has) . We had 4 intubated FULL CODE patients waiting in ER for hours for an ICU bed. They indeed had priority. Why transfer her to ICU when, as a Advanced Care floor, we could weither place her on a low dose pressor and bipap or let her peacefully go without suffering as her and her family wished. The outcome? She was placed on a low dose pressor we could manage and bipap ( which broke down her face over the course of the 3 weeks she was left on it. The kicker......the DOC CHANGED her to a CHEM CODE to do it, dispite the family's uncertainty about changing the code status. She used the family's uncertainty to change the Code Status. She survived and went to an ECF Tuesday after 3 weeks with us. She is no longer coherant, but she is alive.

There are many levels of DNR. The worst is the famous Chem code, "nothing but the drugs". I often have wondered WHY this is an option since if I can't intubate you, or do chest compressions just HOW are those drugs going to magically save you from Cardiac or Respiratory arrest? I have sent many of these to ICU since we can start drugs on them, but many, many of these patients DIE.

DNR ARREST should also go to the unit, after all you are doing everything BEFORE the arrest occurs, and stopping only if you couldn't prevent it.

Anything less than a DNR-CC should go to a ICU or Advanced Care unit to manage vents, drips, post -arrest ect.

Comfort Care patients should NOT tie up an ICU bed because ICU is an EXTRAORDINARY Measure. However, they should be on a floor that is comfortable with managing drips and medications that will keep them comfortable, and treat symptoms.

Remember many DNR-CC patients have multiple system problems. If it is a fixable problem fix it, but if the problem is terminal....let them die with dignity and peace!

PEACE!:heartbeat

Yes, but the problem is that it's different in every state. I'm in Ohio now too, and those categories don't apply. Like you said, it's DNR-CC or DNR-CCA. But they can also be a DNR-CCA DNI - some people are DNR-CCA intubation ok. Every patient is different, and the problem where I work comes "after hours" when someone besides the primary doc for that pt is the one making decisions. Some don't want anything to happen on their watch, so they do all they can to prevent problems, even if that means sending the pt to the unit. Some see "DNR" and are like "why did you call me? Who cares what happens, they're DNR", which, as was previously said, does not mean do not treat. I'm sure other states have the same kinds of problems.

You also have to take into consideration where the pt is in the dying process. For example, they might be a DNR-CC who is UAL but ends up with cellulitis or something similar. Are you going to treat that? Of course! What if they are a DNR-CC who is completely obtunded and actively dying? Are you going to send them to the unit? Of course not.

That's one reason why nurses need to feel the need to speak up around the docs. My hospital is on a big kick now that NOBODY, even the housekeeper, should be afraid to say something if they think something is wrong. And I think that is a great policy. Also, we as nurses, who probably know the pts and their wishes much better than most of the docs do, should have something in mind when we call docs. What do I mean? Well, if you call an intern because a CC-A pt has a high BP, you should have an idea of what you want the doc to order. Some hydralazine or lopressor, maybe, but not tele or a drip. Sure, it's their final decision, but sometimes we can guide them toward where we want to end up. I'm mostly referring to new interns here, but you get my point.

[aeauooo]

I feel bad that you are the one catching the hell about this. The nurses in the unit should realize that this is out of your hands and not take it out on you. To "give you all kinds of Hell" is a type of lateral violence.

Ah yes, the disembodied voice on the other end of the phone.

A few years into my nursing career I paged a resident and got a call back from a circulating nurse in the OR who told me the resident was scrubbed in. I was trying to get some pain medication for one of my patients and the resident, speaking to me through the OR nurse, was giving me the run around. I got so frustrated with the resident I said something nasty and hung up the phone.

This OR nurse, bless her heart, called me back and very calmly told me she knew I was frustrated with the doc, but I had yelled at and hung up on her - not the doc.

I apologized.

We learn the hard way sometimes, don't we?

[OkieICU_RN]

I used to work in an ICU in which the charge nurse interpretted "DNR" as 'withdraw care.' A doc would write a DNR order and this charge nurse would extubate the patient, shut off drips, d/c fluids, and let the patient die.

Oh yes, I argued with this person, who was convinced that this was the correct and only meaning of DNR.

I don't work there any more.

Are you kidding me??? People let her continue doing this?? Did the attending doc not realize this was happening? Did upper management not realize this was happening? Did the family not say something??

Tons of people have DNR orders written and then make a turn around and go home. That's crazy, unethical, out of the scope of practice, etc., etc.