DNI Question

ccemt

ccemt

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Has anyone had to deal with a DNI. Im a little confused!
 
A DNI Means DO NOT INTUBATE!
 
Split off into it's own topic.
 
What's to be confused about? Don't tube them. Pretty simple.
 
DNI: Treatment is still provided at all aspects except intubation. Once it is determined that there is no way to continue to treat the patient without intubation and a ventilator, the doctor will discuss it with the patient and/or family. The patient has the opportunity at that time to chose intubation and reverse their DNI order. Some may do so for a variety of reasons but with the knowledge reinforced that they may need to be trached and spend the rest of their life on a ventilator as was the reason for the DNI order to begin with. The doctor may also wish to try BiPAP as an alternative to intubation as long as the patient can maintain spontaneous respirations. If the patient is not able to make decisions, every attempt will be made to inform the family that the patient signed the DNI and that was his/her wishes. As a paramedic, you, too, will make sure that the family understands the DNI order and that the wishes of the patient should be respected. They should have the knowledge that the patient will still be cared for as long as they continue to breathe on their own.

People who do have a progressive disease process usually hope to die in their sleep peacefully. Once the struggle to breathe begins if it is acute, people get frightened and a natural instinct to want to live kicks in. Many times if the patient comes to our ED and is well known to us, we can provide some emotional comfort along with noninvasive technology to allow the patient to make the right decision and a chance for the appropriate comfort care orders to be an option.
 
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Just went through this last April 20th with my father. He had a long progressive illness that his Dr's could not longer do any thing for (COPD) and was put on Hopice care in his home. Part of the Hospice program was to have a DNR / DNI order that was explained to him and he signed when he was put on the program. During the morning of April 20th he started cheyne stokes respiration's, was unconsious and peaceful, it was hard not let the paramedic side of me not come out and not think about intubating as the apneic periods got longer as time went on that morning , as hard as it was his wishes were honored.
 
DNI / DNR is not legal (enforceable) in our country. A patient may have a living will, but also we have to treat even if the family says no unless enforced by a court of law.

So pretty much we have to treat patients to the full scope of our practice, where possible and under circumstances.
 
Better have that document in hand when I come-a-knocking because I will tube and move you if you don't. I hate DNR's but I always respect their wishes and understand why...I have yet in my young career to encounter a DNI however.
 
A lot of the time, the patients with DNI is included in their "Living Will" portion that included exceptions of what the patient may want or not want performed. Such as intubation, ventilator, medications, even food or water.

This is not to be confused with a DNR.

R/r 911
 
Can't say have really had much to do with "DNI". From what vent explained it is a situation reserved for chronic patients (Expecting the worse, yet still awake to make a choice).

Although i respect the patient's wishes, unless the verbally informs (& sign the PRF) or produces a document worthy of standing up in court, the patient will get the full house.
 
mikeylikesit said:
Better have that document in hand when I come-a-knocking because I will tube and move you if you don't. I hate DNR's but I always respect their wishes and understand why...I have yet in my young career to encounter a DNI however.
Click to expand...

Why do you hate DNRs? It doesn't mean Do Not Treat and many of the things that EMS is called for is actually very treatable such as CHF, PNA and even sepsis.
 
mikeylikesit said:
Better have that document in hand when I come-a-knocking because I will tube and move you if you don't. I hate DNR's but I always respect their wishes and understand why...I have yet in my young career to encounter a DNI however.
Click to expand...

Whoa Cowboy!.... You stated it.. young career. Really, they are not there for you to do something, you should be there for them.. again, it really is their emergency and call, not yours.
I (as well as physicians) much rather see a DNR and things thought and planned out than to "work" or place the patient in an ER/ICU setting for the expected. Really, we do NOT ever stop death, rather only postpone it. The turmoil, unnecessary procedures, and filling a needed bed when not necessary, and yes costs to the patient and system.

AHA and many other well respected organizations have been pushing and endorsing DNR's for decades now. Remember a Paramedic should always be thinking of conservative measures that meets that patients demands and needs, accordingly and appropriately not because we can do so.

R/r 911
 
The only DNI I have seen was in the form of a living will. We can't honor those. You are either a full code, or a DNR. It really sucks, because there are quite a few people that don't understand a DNR. Do not resusitate, not do not treat.

-Kat
 
We use a POLST Physicians Orders for Life Sustaining Treatment. Is very specific down to, you may give water but not food, or pain medication may be given, comfort measures only.
 
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VentMedic said:
Why do you hate DNRs? It doesn't mean Do Not Treat and many of the things that EMS is called for is actually very treatable such as CHF, PNA and even sepsis.
Click to expand...
not my point, i guess i should have specified. i don't like them because they make me feel helpless. it sucks to know that you can potentially do something to save them, it is really bad when you have provided all the patient care that you could and they still die, knowing that you could have potentially saved them had they not had that document.
 
I had an arrest at a rehab facility not long ago - the patient had a "modified code blue". It was the first time I had come across one of these - it basically specified in the event of an arrest - she wanted everything done with the exception of being intubated. It didn't make a lot of sense to me - if you don't want your airway secured in an arrest - why not just have a DNR? It ultimately resulted in death.
 
If the person can not be brought back pharmacologically then the code is over. Some orders include the compressions believing it is required to circulate the meds. By that time a physician is consulted and if there is no chance of survival without a ventilator, the code is over. Of course, there can always be the well meaning family member who will try to over ride the orders.

It again has to do with people interpreting DNR as Do Not Treat. Many things are treatable. Many doctors are reluctant to put a DNR on a patient because they know the patient may be treated differently in their care once they have the DNR status.

When the patient specifies DNI, they may still want to live but only to the point where it might mean going on life support. We will do everything within our medical abilities to turn these patients around quickly before it reaches that point.

Arrhythmias, even V-tach, are treatable and may not require intubation. Hypotensive episodes are treatable.

For these reasons, in the hospital we take those 90 y/o fever patients very seriously from the nursing homes. We do not want them to go on a ventilator and be caught in an ethical dilemma. Our goal is to be aggressive and turn them around before that happens. Then, a serious talk can happen with the patient and/or family (DPOA) to discuss whatever the future holds.

I did not put a DNR on my 91 y/o mother after her AAA surgery because of the Do Not Treat mentality of some health care providers. She, in clear mind, reversed her own living will with DNR instructions for the surgery. As her DPOA, I wanted her to get her meds, including those for pain, and hygiene done on time. I also did not want the EMTs who were transporting her to and from the convalescent center calling her and treating her like just another "BS DNR call". It was bad enough to deal with the iPods in their ears.
 
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mikeylikesit said:
not my point, i guess i should have specified. i don't like them because they make me feel helpless. it sucks to know that you can potentially do something to save them, it is really bad when you have provided all the patient care that you could and they still die, knowing that you could have potentially saved them had they not had that document.
Click to expand...

I understand your point, but remember that you are treating them.. even by not performing anything. As in the The House of God states, sometimes .."the best treatment is NO treatment"... Really, what have you saved .. a shell? We in EMS and medicine need to remember that dying is the final act of living. That we need to look more toward the patient as a person than a condition to treat. Allowing some dignity for the patient in lieu of placing them on ventilators or to appease the family.

How much care did we perform by bringing someone back to life only to suffer for a few additional hours, or weeks? Did we really treat this patient accordingly? The reason I insist physicians implement DNR's on those that meet the criteria.

R/r 911
 
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