Vasoactive Drips with a DNR

allnurses Guide · Nov 2, 2017

I wouldn't use a vasoactive on a hospice patient; but if the family and the patient want to, then yes. Curious to know what the family thought the Levo would accomplish? If they thought it made pt more comfortable? Do they really understand what is happening? Sounds like someone isn't quite willing to let go yet, the change in mentation and all is part of the natural process of dying. Did anyone do a conference with the whole family about what to expect (which should have been done when first entering hospice)?

Our local hospices has restrictions on what treatments can be done, and still remain on hospice service.

Purple_roses · Nov 2, 2017

I see a lot of patients whose code status is listed as DNR/DNI, but Aggressive care ok (meaning vasoactive drips are fine).

I do think that it's ethical to treat hospice patients with vasoactive drugs in certain situations, but from the details given, it seems that this patient's body is trying to let go. If I were the patient, I would not have wanted those fluids or the Levo.

ETA: another point I would like to add (and that I think family should be aware of) is that this is going to keep happening. At which hospital admission will everyone agree that enough is enough?

Nascar nurse, ASN, RN · Nov 2, 2017

Hospice nurse here -

My bullet point responses:

1. I completely agree that a DNR never means do not treat.

2. Hospice, on the other hand, indicates treat for comfort only and allow a natural death. Even though this was "maintaining", it's not allowing a natural death.

3. Hospice doubtfully covered any part of the acute care stay. I would suspect that hospice discharged them from care at the time of hospital admission with the idea of returning them to services once out of the hospital. But, maybe, the hospice service will also claim that this was outside of the qualifying hospice diagnosis, therefore unrelated to their services - but gee that'd be a stretch.

Overall thought, this poor family isn't ready to accept yet and likely needs more education on the end of life process and what to expect moving forward. It's so hard for many - and it becomes hard for all of us too. Best of luck with these patients.

blondy2061h, MSN, RN · Nov 2, 2017

I think we all agree here. DNR usually just means not to resuscitate if the heart actually stops. All treatment up until that point is allowable. DNI adds intubation into the list of things not allowed, but again, allows for all treatment to continue until that point.

On the other hand, hospice is end of life, treatment to maintain comfort only. Sometimes it becomes fuzzy which treatments maintain comfort and which are just life prolonging, however, I think an ICU admission with pressors is certainly outside of the hospice realm and probably put the patient at risk of being discharged from Hospice.

Many patients now have detailed "orders for life sustaining treatment" forms that will say exactly what they do or do not want, including intubation, bipap, feeds, antibiotics, and IV fluids. Certainly a step towards more open discussion. Failing that, solid goals of care discussions need to be held with the patient (if able) or healthcare proxy/next of kin at every step of treatment progression.

MunoRN, RN · Nov 2, 2017

Regardless of Code status of the level of intervention wanted prior to cardiopulmonary arrest, pressor treatment should only be offered when medically indicated, which is to maintain end organ perfusion while a reversible cause is treated. It's not appropriate to use pressors to simply prolong the dying process.

DNR itself doesn't really address the use of pressors, although I worked with a number of intensivists that consider it a proactive resuscitative measure, and are hesitant to use them in DNR patients, I do agree that a declaration of DNR is a good reason to further investigate the patient's pre-arrest wishes.

offlabel · Nov 2, 2017

6 liters of crystalloid and NE? Just cuz didn't nobody push on the chest mean that wasn't a resuscitation. It was.

RNKPCE · Nov 2, 2017

Regardless of Code status of the level of intervention wanted prior to cardiopulmonary arrest, pressor treatment should only be offered when medically indicated, which is to maintain end organ perfusion while a reversible cause is treated. It's not appropriate to use pressors to simply prolong the dying process.

I completely agree.

I have had patient's who come in the hospital who are DNR patient's but are active, independent, Alert and oriented people that if the time comes they don't want "heroic measures" done. Using pressors on a patient like I described that might come in with sepsis related to a UTI is very different than using them on an end stage cancer patient whose body is shutting down evidenced by declining mental status etc, who is on hospice.

Agree a care conference would be helpful.

Susie2310 · Nov 2, 2017

DNR means: "don't resuscitate the patient if their heart stops"; it doesn't mean "do not treat."

It sounded to me from the OP's post that the patient, an end stage cancer patient who had previously undergone chemo/radiation, presented in severe sepsis/septic shock with a BP of 70/45 and was unresponsive to initial IV fluid boluses, and the patient/their family either wasn't ready to give up curative care yet, or chose and was allowed to receive the IV fluids and levophed as part of comfort care interventions for severe sepsis/septic shock. I could see how the IV fluid boluses and levophed could be considered comfort care interventions if the patient was septic. The levophed and more IV fluid boluses appeared to work. I'm assuming the patient received antibiotics too, although this wasn't stated in the OP.

offlabel · Nov 3, 2017

DNR means: "don't resuscitate the patient if their heart stops"; it doesn't mean "do not treat."
QUOTE]
Well, is isn't so simple. What does "heart stops" mean? Asystole? PEA? Audible beating but no pulse? Does a blood pressure of 45/20 mean the heart is still beating? What does treat mean? Inopressor and aggressive fluid or prn morphine and Ativan?

Guest219794 · Nov 3, 2017

We had a small meeting in out ICU today among our nurses and I wanted AN perspective.
Hospice Pt with signed DNR enters ICU from ED. She is a end stage cancer Pt, having received Chemo and Radiation therapy. She was released to hospice care r/t continued growth of cancer tissue. Family was concerned with the Pt status as she has had a declining mental status x1 month, A&O x1-ish and stage 2 ulcers to heels and coccyx.
Pt came into the ED with B/P 70/45*. (50) Pt was not responding to the 3L bolus in ER, so admission to the ICU was made. As Pt was placed on unit and settled in, Doc ordered Levophed, starting at 5 mcG and titrate to maintain a map >65. Pt BP settled into the map >65 range at around 15 mcG of Levo.
Here is the bullet points of our understanding.
Attending nurses
1- 30+ year RN charge
2- 1-2 year RN
1- 5 year RN
We all agreed that a DNR does not mean Do Not Treat.
We also agreed that a Pt whose family wishes to continue DNR should continue.
We also agree that a DNR stops resuscitative measures, but a vasoactive drip is maintaining a BP, not restoring it.
I would also like to get the AN take. Does your hospital have a specific policy on meds with a DNR? Any ethics nurses present?
P.S. Pt is now off the Levo. Seemed that the 6th Liter did the trick.

Experienced ER nurse, with a couple of years ICU here.

I think that the term "DNR" is slippery, especially without concrete definition of "R". Clearly, it is not limited to efforts made when the heart stops. Compressions on a bradycardic ped, BVM of respiratory failure with a pulse are a couple of examples.

I can tell you that when I am doing all effort to keep somebody alive, short of compressions, it sure as hell feels as though I am resuscitating.

And, I see DNR orders changed at the last minute- Asking a dyspneic patient if they want a breathing tube is like asking somebody about to drown if they want a rope. By opting for DNR, they have already essentially said "If my breathing gets uncomfortable and is going to kill me, please keep me comfortable".

In the face of a lack of clear definition, I think it is important to look at intent.

I question the actions in the case you site. "declining mental status x1 month, A&O x1-ish and stage 2 ulcers to heels and coccyx" Thanks to your hard work and excellent care, this person is going to suffer. She made it clear she did not want to suffer when she went DNR. The family over rode those wishes.

I have never understood why that is legal, and know it is unethical.

One of the main reasons I left ICU was cases like your example. I worked very hard to become competent at critical care nursing, and never let my feelings affect patient care. But having to participate in cases like yours made it hard for me to feel good about the work I was doing.

Kudos to your team for exploring the issue.

PeakRN · Nov 3, 2017

What was the goal of treatment? I have kept hospice patients on pressors while also being on comfort care so that their family could come in and say goodbye, and depending on where they are coming from can take several days. Often these patients are septic so we are also being very aggressive with antibiotics with the same goal of extending a couple of days, not healing them to get out of the hospital. All of that being said, comfort is still our primary goal, and if any point treatments begin to cause discomfort or stress to the patient we pull them back.

Honestly we don't care what hospice thinks, if a patient has days left and we are doing the ethical thing we will keep the patient and do comfort care ourselves. We don't let outside policies affect our decisions to do the right thing. Its easy to say that we should have the dying process be natural, it's harder when you have a mom in her 30s who is dying s/p multiple BMTs and her parents want to say goodbye. The person in the bed is not our only patient in that situation.