Those orders need to be clarified at the facility. Most facilities have their own forms. But, this should have been done and you need to be checking with the nurse.
83 y/o N/V + Fever
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Those orders need to be clarified at the facility. Most facilities have their own forms. But, this should have been done and you need to be checking with the nurse.
Families pretty well know if they want a loved one on a breathing machine of any kind. The only other thing in question here is field pressors, with an average transport time of 25 minutes I doubt I would hang these period because it will take that long to find out if the patient is responsive to fluid therapy. Based on current BP it is not even an issue.
Whether the patient is a DNR or not has nothing to do with the fact that we are supposed to treat patients according to their wishes. And if they are unable to make a medical decision then according to the wishes of the POA or next of kin (if no POA). This person could be 30 years old with no previous medical problems, and if he is unable to make a medical decision and the POA does not want a breathing machine used or a tube placed...then it is my moral and legal responsibility to NOT do it.
I am not asking this family to make a decision based on my feelings, I am asking them to make a decision based on their feelings. As far as saying there is no definitive diagnostic data...well...if you think a lactate is the end all then...start treating based on numbers and not patient presentation I guess..
Stop treating patients that DON'T want to be treated....there are way more of them out there than you would think...
VFlutter
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Then they should have never called EMS.
NomadicMedic
I know a guy who knows a guy.
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Let's get back on topic. This is a scenario post, not a debate on DNR patients. It's a good discussion, but one that should continue in another thread.
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Really?
A patient like this that comes into the ER is going to get managed very conservatively until they get a hold of the POA and find out what they want. Do you really think an ER is going to go blasting away with imaging, diagnostics and lab studies on a patient like this without confirming that's what the family wants? There's a reason they go straight to the phone. How are we, as medical providers, any different?
Also seeing as they generally make that phone call early on what do you think the doctor is basing their info that they're giving the family member off? Oh yea...vitals, HPI and a detailed physical exam.
Edit: sorry, just saw that last post...oops lol
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mycrofft
Still crazy but elsewhere
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83 y/o N/V + Fever
1. What specifically was on the "DNR"? No IV, no oxygen, no resuscitation, no transport? No what?
2. Was rash blanchable? Had the family taken the pt's temp lately? (Oddly, you could have them do it as laypersons if you aren't allowed to as an EMT, just attribute it to them).
3. How about EKG, oxygen per tolerated device, transport while clarifying this "DNR" situation? (25 min and a cell phone….what luxury).
4. If some treatment modes are revealed as ok to do, and the remaining time doesn't obviate them, then do them per protocols.
There are three concerns here. 1. What's wrong (directs tx and maybe communicable disease concerns ). 2. What can I legally and ethically do IN THIS PARTICULAR CASE? (directs tx and as a legal defense). 3. In the time given, can you make a difference or are you just satisfying your need to perform your skills?
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Personally the only thing in this specific scenario that I see that could mess with the DNR order is pressors or intubation. Depending on how it's worded an argument could be made against C/BiPAP because it could be considered mechanical ventilation.
The EMS management of this patient isn't going to change unless they decide that they don't want the patient transported or you have a very long transport time.
There is no reason you can't place a NRB, get a line, start fluids and package the patient while you work on contacting the POA. How is that lazy or subpar care? Please explain that to me. This is an "ALS" transport if hey decide they don't want us to do anything and just transport or if they say they want you to do everything. It's my call, I do not care if I sit and chart or if I aggressively treat the patient. Honestly I'd prefer the latter. I hate sitting in the back with a patient that is sick and suffering and not being able to do anything to help them.
Something to address the allergic reaction. It's not uncommon for these patients to have Benedryl prescribed to the PRN for itching or rashes so if you want to treat the rash with IV Benedryl and have a protocol to do so there's no issue there. Even if they don't have an Rx for it I don't have an issue treating it, provided you can support an allergic reaction what says you can't give it under your protocol? After all everyone in here seems to think we think DNR means do not treat...
The EMS management of this patient isn't going to change unless they decide that they don't want the patient transported or you have a very long transport time.
There is no reason you can't place a NRB, get a line, start fluids and package the patient while you work on contacting the POA. How is that lazy or subpar care? Please explain that to me. This is an "ALS" transport if hey decide they don't want us to do anything and just transport or if they say they want you to do everything. It's my call, I do not care if I sit and chart or if I aggressively treat the patient. Honestly I'd prefer the latter. I hate sitting in the back with a patient that is sick and suffering and not being able to do anything to help them.
Something to address the allergic reaction. It's not uncommon for these patients to have Benedryl prescribed to the PRN for itching or rashes so if you want to treat the rash with IV Benedryl and have a protocol to do so there's no issue there. Even if they don't have an Rx for it I don't have an issue treating it, provided you can support an allergic reaction what says you can't give it under your protocol? After all everyone in here seems to think we think DNR means do not treat...
Actually a patient like this that comes into the ER is going to get treated aggressively at first unless someone comes along and the patient is either made CMO or the POA states they don't want a certain intervention. An unstable patient is going to be treated first before the physician takes their time to find some family member and talk them through the different options.
In short, they're going to err on the side of treating that patient instead assuming anything. The liability otherwise is too great.
Same thing when I'm dealing with someone crashing in the ICU, unless they are CMO or I know beforehand specific wishes I have to be aggressive with them until I hear otherwise. As soon as I'm able of course I'm going to get in touch with someone to see how much they want done but it won't be at the sake of waiting to intervene on a crashing patient.
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I'm not saying that the ER does nothing, I guess I didn't communicate that well.
Every single time I've brought a patient, who has a DNR that isn't specific to what is and is not allowed, that's hemodynamically unstable into the ER the ERP starts treating while the case manager works on making contact with the POA. They're not going straight to intubation, central lines, pressors, they're starting early goal directed therapy in the least invasive way possible. Drawing labs, maybe NIPPV if it's indicated, a second line, imaging. Things like that. Hell they might even start antibiotics, I'm not sure.
I've not once seen anyone say write this person off, don't treat them, they're dead.
Yea obviously intubation is off the table with the DNR known but everything else really isn't different from how they'd approach and treat someone who came in with a similar presentation but no DNR. Even in those situations central lines and pressors aren't immediately started until at least some basic work up. My point is mainly this guy being a DNR, besides obviously being a "no code" and no intubation, doesn't really change how he should be approached from an initial treatment perspective. For the most part it's not going to change how I work him up or my initial management. Even a central line or bipap is not off the table.
And definitely wasn't saying or implying that you were saying do not treat. Just speaking to you saying how this patient would be initially treated conservatively in the ED. In my opinion this person is treated no different from any other person who comes in with a similar picture, except for intubation or running a code.
We may have different definitions of "conservative" care as well.
We may have different definitions of "conservative" care as well.
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I can't believe you actually said that. Unless...you're joking, right? I mean, there had to be heavy sarcasm there that just isn't coming across.
How about this for everyone? This is a fairly standard POLST that is used in several states in very similar versions. Please read the ENTIRE form before going on.
https://www.wsma.org/Media/Patients-pdfs/POLST-PrintDownload.pdf
If the OP's patient had declared themself a "DNR with comfort measures only" and had decided against antibiotics and tube feeding...how exactly would he be treated?
OP
OP
rhan101277
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This was a DNR on a physicians order sheet not a standard DNR where items they want or don't want done are checked. If it is on a order sheet I am going to honor it after I verify w/ staff.
The scenario was not "with comfort measures".
But, if it had been "with comfort measures only" I would hope you would treat this patient with comfort measures which includes pain medications and oxygen if that is what the situation calls for clinical signs which means more than just an SpO2 check. If your protocols allow for nebulizing fentanyl or morphine that is also an option for a patient expressing shortness of breath.
VFlutter
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No, I am not joking. That was a response to the comment...
If the patient and/or patient's family truly does not want treatment as in "Comfort Measures Only" then they should not be calling EMS and certainly not be transporting to the hospital. Most of these type of patients have home health and hospice care. There is nothing we should be doing for these patients, even IV fluids are prolonging the dying process.
However If the patient just has a DNR that is not specific other than no CPR/Intubation then by all means call 911 and transport. My treatment for that patient is no different than a full code patient. I do not assume that a DNR patient wants as little done as possible, as he implied. I assume the opposite, that they want aggressive treatment up until the point of cardiac arrest and want all reasonable interventions to prevent a cardiac arrest.
I will try to scan a copy of our DNR order form. The wording is similar to what I just described "Aggressive treatment will be provided...".
They should not be treated nor transported. They should be given their comfort medications and that is it. What do you think we are going to do for them when they get to the hospital?
That would depend on the reason called. Some cancer and AIDS patients are in hospice for comfort care but still get a limited amount of treatment such as replacing an infected port or PICC or even foley which could be causing discomfort. The idea is for "comfort" throughout the dying process and not to allow what can easily be corrected to cause more discomfort.
But, I agree if the family called 911 they may have a good reason and a family member can fight a DNR. Sometimes they are the DPOA and sometimes they are not. This is why we have Ethics Committees and Physicians with legal advisors on call.
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VFlutter
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Agreed but does that require an ER visit or hospital stay? (Aside from the PICC/Port) If the patient has absolutely no assistance then sure but the majority of these patients, if not in a LTAC or SNF, will have some type of home health care. It can, and should, be handled outside of the acute care setting.
True but not all patients follow a recipe. Other body parts can break either bones (not necessarily from falling) or become diseased. We had one teenager at the beginning of hospice care who got a very painful tooth abscess which required extraction in the hospital. Another got appendicitis which really presented a dilemma.
This is a great discussion topic which I would be willing to continue on a nursing forum with you and others.
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I don't mean to be rude, but you clearly do not understand why people call 911, who is calling, or what type of "comfort care" may be needed. Many people call because they aren't sure of what to do, are panicking, don't know what the actual patient wants, or because they are required to (for someone living in an assisted-living center for instance). While the actual patient may not want care, (or even need care in some cases) the simple fact that 911 was called does not in any way, shape, or form mean that they have consented to treatement. Rialagh is very right; we need to stop treating people who don't want treatement.
This of course ignores the fact that "comfort care" is very much something that we can provide to many patients, and should when appropriate. Sometimes this very well may mean that the patient is taken to the hospital.
I'm sorry, but this is patently, and blatantly false. Many, many, many people have a DNR with comfort measures only and are leading normal lives without any sort of hospice or in home care, nor do they need that type of care. They simply know that they want to die peacefully and naturally when it happens. As is very much their right.
Please do. I would be very interested to read the entire thing.
VFlutter
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Many, Many, Many people? Maybe it is more prevalent in your area however I have never seen a single patient come in with a "Comfort Measures Only" DNR that was leading anything close to a "normal life". I have seen many people who have DNRs that come in who are quite independent and relatively healthy, but we are talking about two totally different things. I have also never discharged a patient home on comfort measures without some type of in-home care. Which I do on a weekly basis with many of our end stage patients.
By the definition of "Comfort Measure Only" DNRs it declines any life prolonging treatments. They will not receive IV fluids, IV abx, or any form of treatment other than pain/anxiety/etc. In reality they are sent to the lowest level of care bed available and either die or get discharged back to where they came from.
I do not know many people who are living normal lives who choose to die from a UTI or would refuse treatment for an allergic reaction. But obviously it seems that you know more than I do.