Would you call a code/MET on a pt. who is a complete DNR?

Nurses General Nursing

Published

Sorry if this is a stupid question, but I'm a new nurse, freshly graduated.

If I walk into the room of a complete DNR pt and he/she is unresponsive, diaphoretic, breathing is labored, should I call a MET/Code?

Thanks...

Thank you all who have responded. The general consensus is that I would call an RRT/MET but never ever a code. I was never sure if I would be frowned upon by calling a RRT. If all else fails I can always seek the advice of a more experienced nurse. I just don't want to call them if the patient is actively dying and it's their time to pass on...and nothing can be "fixed". And I definitely never want to try to fix something and end up causing pain and discomfort to the patient. Such a fine line to me....

Its always best to confirm with the family if the patient is DNR as well. I had a situation where the attending physician had noted the patient as a DNR, when i admitted her on our floor, I asked once again "to confirm" that this is what the family wanted. The patients family was upset because according to them, they never told the attending MD that they wanted their family as a DNR. It was a misunderstanding between the MD and the family as things weren't exactly explained in lay terms to them. Long story short, the family requested to have a different MD....what a mess!

So regarding comfort measures...if you give pain medicine to make them comfortable and the patient expires....then what? :eek: I've always wondered this...

My mom became uroseptic in AZ while there for the winter- dad had to fly back with her (left car and everything he didn't have in his pockets) since the hospital there did not admit her even with seizures and unresponsiveness (usually was AMS- but could talk, go out on outings and enjoy them, transfer with a loopy technique that worked for her and my dad :uhoh3:, etc). Brought in by EMS- and sent home (rental in AZ) after 3 people put her in the car. :down: SO, they get back here, and we go straight to the hospital (I was with them after picking them up at the airport in a van w/dad's friend).

Her vitals were 'iffy' on admission (late night)- but she was alert enough to recognize her doc by name. The next day, the mottling started and by nightfall, she was essentially comatose (a moan here or there). BP was tanking ( only got it by doppler- at 50mg/hg). She was like that for another 30 hours or so. I stayed that 2nd night , and her breathing got more rapid- the nurse called for morphine and lorazepam (also had seizures- so double duty :)) after I'd asked for it (they didn't use scopolamine- which surprised me). It helped. She calmed down and rested peacefully. :)

Later in the second full day, her breathing was horrible again. I asked for the lorazepam (not time for morphine yet- and she wasn't conscious- but restless and looked distressed). Her BP was still around 50 systolic w/doppler. She got the lorazepam. Within 10 minutes she was dead.

Normally, IV lorazepam would not be give with a SPB of 50. But normally, people aren't mottled, unresponsive, and circling the drain. And had "the smell". The lorazepam did not kill her (her poor nurse was a wreck though- and I said nothing to dad....he would have nightmares about it, and there was no need- she was actively dying with or without lorazepam). She had gotten both the morphine and lorazepam with a 50 SBP during the 18 hours or so before she died.

It still was a lousy situation - but just after she died, her face relaxed....and she looked like she had before dementia, brain radiation from CA, lung CA, and bilateral breast CA- which she had survived 17 years. It was incredible- almost like some release of the torment let her body relax. The meds helped that. They may have sped up what was ALREADY happening- but they allowed her to "go in peace".... that was a huge gift to me. and since I understood the medical processes going on, and could explain to dad- HE was able to see her death as calm, and had no guilt about heroic measures not being done.

Where she MAY have had a chance is if she'd been admitted for IV antibiotics in AZ.... but "the hospital was full" (story given to dad :mad:- like Phoenix didn't have more than one hospital :uhoh3:) but that's not something I'll ever know (just that they were idiots). AT least she didn't end up in LTC curled up on a bed, not knowing any of us. But they saw "DNR" and dementia- and wrote her off. I have the ED records...I couldn't believe the "care" and needed to see for myself. But it was done. Admitting a DNR for antibiotics and fluids would have been appropriate (she was at an art opening the day before- not like she'd gone on for days sick- it was VERY acute).

I think it should also be clarified if a patient is for escalation of their care. Example: Are they for admission to an ICU? Are they for BIPAP but not Intubation? Inotropes but not Defib? Its important also that you clarify with the doctor at the time to document the DNR details well and that everyone is informed appropriately. Also we shouldn't be scared to question a clarification from the doctor and request them to document the plan well. We need to protect ourselves and the patient. At the end of the day it doesn't hurt to call the resident if your concerned at all.

Specializes in Medical Surgical.

Hospice, does not need a doctor referral. Anyone can call, even a family member, or a neighbor. Hospice does a lot for people, its a shame to try and keep them away from hospice till the very last minute.

I get doctors from the ICU calling all the time saying, were sending this pt home from ICU, and we want you to admit them tonight! They are probably going to die in a few hours! They end up going home and dying not on hospice. Hello people, its does not happen that fast, we are clinics! It takes days sometimes to get admitted to hospice....so the doctors that are waiting this long are so misinformed about when to call us. We do so so much for family's once they are admitted, its been shown that early referral to hospice can actually prolong pts lives. And it improves the quality of life they have left. Anyways.. anyone can call, not just doctors.

Specializes in Med/Surg, Academics.

Yes, I have. A DNR/DNI who became suddenly short of breath with a skyrocketing BP where I suspected flash pulmonary edema. O2 on Lasix given, and it started a whole chain of communication b/w the MDs and the family about palliative or hospice care. There were no notes about those conversations taking place until after I called the RR. I did get an eye roll from the ICU nurse, but the senior resident thanked me because it got the ball going on conversations that needed to take place. The patient was hospice and off the unit by the end of shift.

Hospice, does not need a doctor referral. Anyone can call, even a family member, or a neighbor. Hospice does a lot for people, its a shame to try and keep them away from hospice till the very last minute.

I get doctors from the ICU calling all the time saying, were sending this pt home from ICU, and we want you to admit them tonight! They are probably going to die in a few hours! They end up going home and dying not on hospice. Hello people, its does not happen that fast, we are clinics! It takes days sometimes to get admitted to hospice....so the doctors that are waiting this long are so misinformed about when to call us. We do so so much for family's once they are admitted, its been shown that early referral to hospice can actually prolong pts lives. And it improves the quality of life they have left. Anyways.. anyone can call, not just doctors.

Anyone can refer a patient to hospice, however, a doctors order is needed for the actual admission to hospice.

Also, it should never take days for a patient to be admitted to hospice unless the family or doc are dragging their feet for some reason. I am a RNCM with hospice and our company has a 3 hour admission window from the time of the referral, 24/7. If its a patient in the hospital and we are going to admit GIP I've seen them done in less than an hour (and we are not affiliated with any hospital).

MRT yes. Code? No.. I guess im confused what you mean by "complete" DNR. Because in my experience there is no "half DNR". you are either DNR or you are not, there is no in between.

But to answer your question...Yes, you could call an MRT. A DNR is different from P-DNR (if that's what you meant by complete?). But a P-DNR you do nothing except make them comfortable through that process.

just a DNR, yes you would call an MRT. Although you would not to CPR if it came to that, there are other measures that could be taken. Maybe their blood sugar was low and they just needed a little D5. Or maybe they need a little Lasix? You never know. DNR, you still can medicate and still do every measure except CPR (and intubate in some cases). So..yea, you would call an MRT for a DNR but not a P-DNR. get it?

This largely depends - DNR doesn't mean do not treat. I may have a pt who is a DNR who is perfectly alert and oriented, mostly independent and in with cellulitis. If I walk into the room and they are unresponsive I'm calling a MET call - maybe they had an MI or stroke and need treatment ASAP.

If I have a pt. that is deteriorating over the course of week, and eventually has poor sats, bad vitals/labs but has expressed to me they want everything done short of compressions/being intubated, I'm calling a MET call.

If I have a pt that has been poor, family knows they are poor, pt has no plans to ever recover etc. then I would treat whatever symptoms they have, oxygen, lasix, etc.

I always try to evaluate which patients want comfort care/hospice, vs treatment but not compressions, etc. I think so many people are hesitant to sign a DNR because they think we will no longer treat them. And unfortunately I've been in many arguments with MD's because they think the patients DNR means they are comfort care, when the pt. has clearly expressed that they want treatment. I may not agree with it, nor the MD, given the patient's condition, but its not really our decision to make.

So regarding comfort measures...if you give pain medicine to make them comfortable and the patient expires....then what? :eek: I've always wondered this...

Then you say a silent prayer that when it's your turn to die the nurse who cares for you does exactly the same thing to relieve your suffering at the end.

People die. Death is natural. Death is not the worst thing, by a very large margin, that can ever happen. Death is not automatically, finally, and forever something to be afraid of.

When someone has a DNR, that person, or the guardian/next of kin/parent who knows him/her best, knows that means death is preferable to more "care"; that person has likely seen his grandparents and parents and maybe siblings die, friends, and more; he has suffered or seen the indignities and discomforts of progressive disability and loss in his life and knows there will be more; he knows what death is and does not fear it. Do not fear it for him-- that is not your role.

Specializes in Oncology.
Then you say a silent prayer that when it's your turn to die the nurse who cares for you does exactly the same thing to relieve your suffering at the end.

People die. Death is natural. Death is not the worst thing, by a very large margin, that can ever happen. Death is not automatically, finally, and forever something to be afraid of.

When someone has a DNR, that person, or the guardian/next of kin/parent who knows him/her best, knows that means death is preferable to more "care"; that person has likely seen his grandparents and parents and maybe siblings die, friends, and more; he has suffered or seen the indignities and discomforts of progressive disability and loss in his life and knows there will be more; he knows what death is and does not fear it. Do not fear it for him-- that is not your role.

TRUTH! I consider if a small accomplishment if someone dies on my watch and I know they did it as comfortably and with as much dignity as possible. When I first started on my unit I asked an older nurse how she was able to handle so much death for as many years as she had worked here. Her response has stuck with me all this time: "I'm not causing their death. These people are dying whether I am here for them or not. When I am here for them, I know I am doing what I can to support their family, make them comfortable, and help their dignity. That is an honor, not a burden."

Some of these responses are making me nervous. Read the patient's code status. Comfort care, DNR/DNI--no escalation: assess and call MD for symptom management and so family can be contacted if necessary. Neither of the two? Full steam ahead. Some of my busiest shifts have been with DNR/DNI patients. I did everything short of chest compressions and intubating. High O2, multiple drips, central line, etc. It doesn't matter how advanced their disease process is, that's not your call to make. You do everything you can until the patient or family say stop. Getting some eye rolls from the rapid response team is better than someone accusing you of doing nothing when something could have been done.

+ Add a Comment