Which way do you go?

loricatus · Apr 1, 2007

What did the orders say?

Personally, when I see a DNR pt. starting to plummet, I won't let myself get into a mindset that would allow me to hasten their death through subjective decisions about treatment. I see too many others I work with view a DNR as a DNT (Do Not Treat). Eg, "why bother suctioning since it means they will only suffer longer" "I'm not going to turn the pt, since by the time they go, a pressure ulcer won't matter and I'll only make them more uncomfortable turning them", etc. If a drug is ordered and cannot be d/c, there is an obligation to use the drug for its intended purpose, unless the dosage was fixed by the MD. When it comes to extending the suffering, I keep in mind that some cultures/religions welcome it and consider it redemptive-basically, I ground myself realizing that the suffering is a subjective viewpoint. I am not saying I want to prolong someone's suffering, I just try to respect that everyone can see it differently. It is my job to do what is best for my pt., from my patient's perspective. When I can't find that out from the pt., I'll try to get an idea from whatever resources are available. Learning to take things from this viewpoint, I have never had to deal with second guessing whether I was right or wrong (in situations like you described), I take comfort in knowing I tried my best to do what the patient would have wanted, because I tried my best to discover the clues towards the patient's wishes.

Don't second guess yourself. I'm sure that you did the right thing for the patient or you would have turned that drip down the moment you saw it was increased. It is probably the suffering that has you second guessing yourself. Was that person possibly the type that would have wanted it that way and you were only fulfilling their final wishes? I kinda think so because you wouldn't have posted this unless you were the type of nurse that cares.

burn out · Apr 1, 2007

Wow, it is amazing how insightful you are, you are so right about second guessing about the suffering. You think when these people are made a DNR, ( and she made herself a DNR as one of her last conscious actions) that their passing will be peaceful. But listening to her moan all day and the morphine not lasting long enough and the doctor not increasing the dosage or frequency, and then listening to her lungs fill up so much you couldn't even escape the sound at the nurses desk. Watching her vital signs as her body struggled to stay alive and wondering "is this really what she wanted?" and knowing the alternative was far worse . I guess maybe no this isn't what she wanted but it was the hand dealt to her, I just wish I could have given her more morphine.

By the way the doctor said to keep the neo where it was at the 170 but not to increase it anymore.

Thank you for your insight, only someone who has been there would really understand.

nurse4theplanet, RN · Apr 1, 2007

This tends to become a very gray area on our unit. DNR itself is vague. "Do Not Resuscitate". Okay, no chest compressions and do not intubate. What about these pressors I have got running that are maintaining this patient's pressure? Oh, you're going to put in a vas cath and start this pt on hemodialysis? Okay, we have exhausted how many units of blood products?

It becomes frustrating and emotional. You have to follow the doctor's orders, respect the family's wishes, maintain pt dignity and advocate for your pt's well-being, stay within the law, and ensure that everything being done is ethical, etc.

I understand the difference between DNR and DNT...you would not let a pt go untreated with a UTI simply because they are a DNR. However, if you have a pt who has terminal cancer with mets to the brain and is diagnosed with sepsis and ends up in renal failure...should you load them down with antibiotics, blood products, pressors and start hemodialysis? (True example...the ethics committee began to review the case but pt died shortly after going into respiratory failure...family did not want to intubate)

There is a point when treatment is futile and only prolongs suffering/postpones death.

I think that physician's could do a much better job educating the family on DNR status and the patient's realistic prognosis. Do they receive training in this type of interaction or is one of those things that is learned OJT? Some of our docs can be very blunt and insensitive while others seem to do whatever the family wants regardless of what is best for the pt.

I guess the best thing to do in this situation is to call the physician and get clarification. That is what the nurse should have done before increasing the neo. I would not have decreased it once I discovered it had been increased by the other nurse, but I would have called the doc and got an order to leave it at a set rate.

Hoozdo, ADN · Apr 3, 2007

I'll try to keep this short. I had a patient with liver cirrohsis end stage, stuck on a phenylepherine drip currently at 130mcg/min when she was made a DNR and progressively slipped into coma. Numerous attempts had been made to wean her off the drip prior to dnr status but she failed every attempt even after adding proamitine. Slowly amonia levels reach 80 Bun 104 she is unresponsive not on a ventilator just stuck on the neo. At shift change I reported to the oncoming pulled floor nurse that if the patients blood pressure drops not to increase the neo. We could not withdraw it (proper procedures were not done to withdraw life support) but we do not increase it. Sure enough the patients bp dropped during the night at 5 am and she increased the neo to 170 mcg/min which ended up having the patient spend another 12 hours suffering. My question is should I have decreased the neo back to 130 when I came on which would have hastened her death or just left it alone at 170 and wait?

I have had this same situation, (different pt circumstances), about 3 times in the last six months. Pt is DNR, pressors over double the max dose....prolonging the inevitable that is going to happen eventually. In the meantime, the pt is suffering longer than they should and the family is all wringing their hands about what to do. Luckily, these patients all had families that were there for them. After some gentle persuasion by nursing staff, they all agreed to withdraw pressor support and let the patient go. It is a rare doctor in my facility that has the time for this type of family interaction and to build this kind of rapport with the family to make this decision. Then, I of course, get an order to d/c pressors and one for comfort care only.

With your case, I would of left the neo at 170 and called the doc for an order not to increase it.

burn out · Apr 3, 2007

Thanks for the supportive comments. It helps to know that others would do what you did in that situation.

As an update the patient passed away one hour and 46 minutes after I left.

When I reported off to the night shift nurse coming on that night he just said "Oh no" when I left he was at the IV pump. Now I can't help second guessing if he reduced the neo back . Maybe I am just paranoid and suspicous. I should just ask him .?

Indy, LPN, LVN · Apr 5, 2007

Yeah, ask him. You won't know otherwise, and it's good for the shifts to communicate with each other. I'll frequently ask the nurse who followed me on difficult cases for some insight or "how'd they do?" and it's usually educational, sometimes cathartic, to discuss stuff like that. Although for the DNR patients I've seen it's usually "so when did they go? did they need more morphine or did I leave them okay for you?" etc.