With-holding resuscitation on pt in the absense of a signed DNR order form? What?!

[Cat_RN, ASN, BSN, RN]

This is something I would like clarified as a recent situation has drawn up some questions. I feel my DON is VERY in the wrong here. She is trying to tell us that here, in the state of FLORIDA, one does NOT need a YELLOW DNR order formed signed by the physician and the patient or DPOA to WITH-HOLD CPR on a pulseless pt. Nurses are having action taken against them because a pt was unsuccessfully coded who was supposedly a 'DNR', but her chart was absent of that signed YELLOW form. The DON told us that if the pt had a T.O. the doc's signature on it and that's it that it was sufficient enough to not code a pt.

I was ALWAYS taught that in the absence of that signed DNR form, you are to code any and every pt. She is trying to tell us that a T.O. signed by the doc is good enough not to perform CPR!!! I have never talked to anyone who would echo this statement! We all KNOW it has to be that yellow DNR form totally filed out in order NOT to code the pt. Are we all crazy?

There are so many things with wrong this.

Please help I need your input!

[BluegrassRN]

I've gotten telephone orders from docs for DNR before. I've had docs order DNR in the absence of written advanced directives, after conversations with the next of kin (this happens a lot where I work).

I don't know if that is exactly what you mean, but yes, I've withheld CPR on a patient who was declared a DNR via a telephone conversation with the doc (we have two nurses listen in and sign off on it). Just because there is not a written, completed form does not mean that a DNR is not valid if there *is* a physician order for it.

ETA: I am not in Florida, but I am in the US.

[OkieICU_RN]

I have taken a telephone order for DNR as well (with a second nurse on the phone as a witness). Both nurses sign off in the chart as hearing the order.

I have never worked in FL so I can't speak specifically to your state. Perhaps you could post this in the FL state nursing discussion board. I would suggest checking your policies and procedures at the hospital concerning DNR orders. You could also just call risk management at the hospital and ask them what is required. Lastly, contact your state board of nursing and ask them what is acceptable and/or required.

[Cat_RN, ASN, BSN, RN]

I am so confused. I was always taught, (and always thought), that it was negligent to withhold CPR on a pt without that signed yellow form. And also that the DNRO isn't valid if it's not yellow.

What if a doc writes 'DNR' on the wrong pt? Perhaps he is thinking of one pt while writing DNR in another pt's chart and makes an error? Don't we need documented evidence that the pt or the pt's DPOA also consents to the DNR?

[BluegrassRN]

I am so confused. I was always taught, (and always thought), that it was negligent to withhold CPR on a pt without that signed yellow form. And also that the DNRO isn't valid if it's not yellow.

What if a doc writes 'DNR' on the wrong pt? Perhaps he is thinking of one pt while writing DNR in another pt's chart and makes an error? Don't we need documented evidence that the pt or the pt's DPOA also consents to the DNR?

In our charting (we have electronic charting) there is a required space for documentation of how the DNR was determined...previous DNR (per old chart), discussion with pt, discussion with family/DPOA. With the electronic charting, there is no paperwork. No forms of any color, so the color of the form does not indicate validity.

Paperwork can always be filed under the wrong chart. A yellow paper could be filed under the wrong chart, too.

I wonder if the yellow paper thing is specific to your facility. Or maybe your state?

[Boog'sCRRN246, RN]

I'm in Florida and the DNR forms we have in our charts aren't yellow; they're either a form that's filled out and signed by the MD or it's written on a T.O. sheet (after the order has been heard and confirmed by two nurses). I have seen the yellow sheet you're talking about though, I believe those usually come in with the patient on admission.

[NurseLoveJoy88, ASN, RN]

As long as there is an order on file then it should not have been an issue. I'm thinking a T.O would be sufficient.

[RNTOBE_1970]

What is the policy of your facility?

[usalsfyre]

I work in EMS, we deal with this on a regular basis. One of the biggest myths is there must be a state form present for DNR patients. In the case of a signed order, initiate resuscitation and contact the patient/oncall physician (or in our case a medical control physician) for guidance.

[3dayRN]

I was always taught a telephone order from a doctor is NOT valid. Where I work if a DNR order is written we must then get a signed DNR paper on the chart. When my grandma was in the hospital she was asked about being a DNR, my sister and I were both present in the room. She said she would have to think about what she wanted and NEVER signed the papers. The next day, again my sister and I were both present, a nurse came in with a DNR wrist band and attempted to put it on my grandma. We stopped her and said my grandma never signed the papers and in fact the blank papers were still on the counter in the room. Now, you want to know what her reasoning was for putting that wrist band on....you guessed it, she said there was a doctor order for it. Never trust JUST a doctor order for something this important.

[NotFlo]

I work in EMS, we deal with this on a regular basis. One of the biggest myths is there must be a state form present for DNR patients. In the case of a signed order, initiate resuscitation and contact the patient/oncall physician (or in our case a medical control physician) for guidance.

So you are saying in the case of a SIGNED ORDER for the pt to be DNR, the nurse should start performing CPR and contact the doctor for guidance? This doesn't make sense to me, if the MD already signed a DNR order why would you start CPR and call the doctor about whether or not you should be doing cpr?

[NotFlo]

This is something I would like clarified as a recent situation has drawn up some questions. I feel my DON is VERY in the wrong here. She is trying to tell us that here, in the state of FLORIDA, one does NOT need a YELLOW DNR order formed signed by the physician and the patient or DPOA to WITH-HOLD CPR on a pulseless pt. Nurses are having action taken against them because a pt was unsuccessfully coded who was supposedly a 'DNR', but her chart was absent of that signed YELLOW form. The DON told us

that if the pt had a T.O. the doc's signature on it and that's it that it was sufficient enough to not code a pt.

!

I don't know how much help all of us not in Florida will be.

In my state, we can accept telephone orders for DNR, but the order is only good for 24 hours and then it must either be signed by the MD or another telephone order for another 24 hours must be obtained. When determining if someone is a DNR we go right to the orders section of the chart, the secretary puts the sheet that has the signed DNR order in a plastic cover so it's easy to find, and we go by the order. It can either be an order that the doctor wrote himself (usually just says date DNR/DNI/NMP Dr. So and so) or a telephone order that was written by a nurse and TO'd within the past 24 hours.

There is a form that social services goes over with the pt. /family where they check if they want to be a DNR or not and sign, but that is not a legal DNR order, that form isn't valid unless the order is written in the chart.

We don't have a special form and definitely don't have any kind of yellow form.