DNR and assisted ventilations.

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dacrowley

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I'm sure the answer is on here somewhere, but I searched and couldn't find it. So:

You've been called to the scene for 70yo male with irreversible kidney failure, due to the onset of pneumonia with associated DIB. Hospice nurse is on scene and is the one who called. Wife brings you a DNR for the patient. Pt is breathing 8-10 times a min with rales and wheezing bilaterally.

Am I correct to assume that as long at this pt. is breathing on their own we can provide respiratory assistance with a BVM, but if they become apnic (but not pulseless) we must stop ventilations? Or do we continue ventilations until the patient become pulseless as well? :huh:

Thanks.
 
Depends how the DNR is written, but most only go into effect when the patient is pulseless or apneic. If he has an advanced directive as well stating no "heroic measures," "no life support," or palliative care only, that would be a different scenario.

Now for my own curiosity, why did the hospice nurse call? What is she hoping will happen after your arrival?

Also, I kind of laughed at your DIB abbreviation. I'm sure you mean Difficulty in Breathing, but the term I use most often for that is SOB. To me, DIB is Dead in Bed :)
 
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DNR does not mean Do Not Treat. Comfort measures like oxygen therapy would be appropriate. Ventilation, possibly. What does the wife want done?
 
The hospice called for transport of the pt to hospital for treatment of the developing pneumonia. In this case the wife assumed us using a BVM to assist with ventilations as resuscitation attempts, even though he was breathing on his own with difficulty.

Lol... pneumonia with associated Dead In Bed... I can see why you chuckled. I used to use SOB, but I've come to understand that term isn't 'PC' anymore.
 
Bare in mind that if they are on hospice and you transport, then the pt is discharged off of hospice which discontinues the DNR orders. It also means that, should the pt recover to the point of discharge from hospital, they might not be allowed back on hospice, or at least with that hospice company.

Artificial ventilations, even BVM, is called "life support". Keep that in mind when faced with a pt with valid DNR orders.

Also, changing level of care; hospice to hospital, outpatient to inpatient, ICU to floor, inpatient to home, discontinues all previous orders and they have to be rewritten. Including DNR orders.

Need to varify with indigividual state.
 
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Slowed breathing and fluid in the lungs is not uncommon with the end of life. 8 to 10 breaths a minute? I would consider O2 for comfort measure and ask the nurse to call his doctor. If the patient is alert, the bvm is going to be uncomfortable to him.
If the patient is on morphine this isn't uncommon.
Bedridden patients develope fluid in the lungs.
I think it is best to ask was this causing pain to the patient? It is not our choice really to transport, but the patients. Does he want transport? Maybe consider calling ahead on this one.
Why wouldn't the hospice nurse know these things?
 
MSDeltaFlt said:
Bare in mind that if they are on hospice and you transport, then the pt is discharged off of hospice which discontinues the DNR orders. It also means that, should the pt recover to the point of discharge from hospital, they might not be allowed back on hospice, or at least with that hospice company.
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Why would the hospice company discharge a patient because he was hospitalized for something that deserves hospitalization?

Why is the DNR dependent on hospice status?


Also, changing level of care; hospice to hospital, outpatient to inpatient, ICU to floor, inpatient to home, discontinues all previous orders and they have to be rewritten. Including DNR orders.
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While the medication orders at my hospital has to be rewritten when moving to/from ICU (which, in all honesty, is a form printed out from the electronic medical records), the DNR is still operative.
 
JPINFV said:
Why would the hospice company discharge a patient because he was hospitalized for something that deserves hospitalization?

Why is the DNR dependent on hospice status?




While the medication orders at my hospital has to be rewritten when moving to/from ICU (which, in all honesty, is a form printed out from the electronic medical records), the DNR is still operative.
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Yes, the DNR, especially an official form like VA's durable DNR, travels with the patient, at least under VA law. The family has a bright orange or yellow piece of paper that stays with the patient, in the chart, in the home, where ever.

I would never feel comfortable providing positive pressure ventilation of any sort to someone at the end of life on hospice care. Not saying that I haven't participated in anxiety-driven melodrama on the part of the families, in hospital and out, that had end of life patients, but it's completely antithetical to what hospice is about.

I would administer meds for comfort if the patient looked uncomfortable, but no on the BVM, and I really wouldn't want to use CPAP either, given a circumstance in which it was appropriate.

Were it my personal loved one on hospice care, I doubt we would treat the pneumonia. Everybody dies. Prolonging the misery at the end can be dishonoring and unmerciful.
 
I think the problem here is some don't actually know what hospice is and automatically mean the patient should die. Hospice is about improving the quality of life for the time left. This can include being treated for things which normally would not cause death. For PNA, the patient can be ventilated by BIPAP and can also be intubated in the hospital to be treated. Their DNR will remain even while on the ventilator. It just means if their heart stops they will not be resuscitated.

When in doubt, call the patient's physician and/or your med control for advice.

Maybe some here should attend an inservice or get a rep from a hospice agency to give a lecture about the services they do provide.
 
MSDeltaFlt said:
Bare in mind that if they are on hospice and you transport, then the pt is discharged off of hospice which discontinues the DNR orders. It also means that, should the pt recover to the point of discharge from hospital, they might not be allowed back on hospice, or at least with that hospice company.
...
Need to varify with individual state.
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Not in NC. The DNR or MOST is valid, hospice or not. Hospice has no say in the patient's DNR/MOST status.

They may not take on a patient who lacks DNR/MOST status, but they certainly cannot revoke it.
 
Christopher said:
Not in NC. The DNR or MOST is valid, hospice or not. Hospice has no say in the patient's DNR/MOST status.

They may not take on a patient who lacks DNR/MOST status, but they certainly cannot revoke it.
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But, in this situation Hospice is not revoking the DNR. Requesting treatment is not revoking the DNR. The patient's heart has not stopped. PNA is treatible. The goal of Hospice is to decrease suffering and improve quality of life. Hospice does not mean the patient is going to die from their disease the same day or even in the next few months. If this nurse denied the patient their right to treatment as explained in a Hospice admit process, that would be very wrong and grounds to take action against his or her license.
 
Clipper1 said:
But, in this situation Hospice is not revoking the DNR. Requesting treatment is not revoking the DNR. The patient's heart has not stopped. PNA is treatible. The goal of Hospice is to decrease suffering and improve quality of life. Hospice does not mean the patient is going to die from their disease the same day or even in the next few months. If this nurse denied the patient their right to treatment as explained in a Hospice admit process, that would be very wrong and grounds to take action against his or her license.
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I wasn't commenting on that bit. I was commenting on the bit where MSDeltaFit stated hospice could "revoke" it. There is a difference between treating in spite of a valid DNR/MOST and "revoking" a valid DNR/MOST.

(I have no qualms with treating DNR/MOST patients, didn't know that was the issue I was addressing)
 
As I said, verify with your state.
 
What does the wife want...that's what the patient gets, I would be very hesitant to use any manner of assisted ventilations unless the wife really wanted it, In which case I would be happy to oblige, if the wife wants O2, thats fine, if she adamantly does not want even a simple o2 mask or cannula and the patient is not begging for one either, that's fine too. I do as little as possible for this patient and basically anything the wife request.

Best thing for this guy is a comfortable pillow, a blanket, and a ride to the hospital where the wife and the patient can speak with a physician to make more in depth end of life plans.
 
One of he big obstacles which keep some patients from entering a hospice program is the concern they are labeled as already dead and can not get treatment. It is much the same as the DNR only worse. Many patients in SNFs will not sign a DNR nor will their families because they think all they'll get is a pillow and a corner to die in. This is why most Hospice nurses are involved in the planning and on going education of the patient and their family. This education really needs to be extended to other caregivers such as EMTs and Paramedics.

If this is a new acute illness, it should be treated as such unless you plan on intubating. ANY concerns you have should be addressed with the physicians either your MD or the patient's. But, refrain from getting into a major "protocol" argument at the patient's bedside. Nothing worst then having a patient feel helpless if they don't "fit" your protocols. Every patient is in hospice for different reasons and some will have months to go before their terminal illness finally ends their life.

Fine out what the goal of the call is and treat accordingly. Put aside your negative feelings about "hospice nurses" and talk to them. They have a tough job also and will have to document their decision process very carefully. Hospice is supposed to be about quality of life be it pain free and comfortable or a hold over until a decision about more treatment is made. If a patient needs oxygen, please don't withhold it. If the patient needs pain medications, see what they have been getting and give more as appropriate. This should not be a guilt trip to lay on the wife. Explain what you will do but please do not make it sound like this is going to be a burden of a decision. The whole process of watching someone you care about die is tough enough. Often the Hospice RN is speaking for the family since he or she has be doing the education and carrying out the care plans which have been laid out by the family and the doctors. Talk to the Nurse, the patient and the family but first find out more about hospice and the process before being so judgmental about the treatment.
 
If this is a bacterial or viral thing, by all means, he needs treatment. A bvm for assisting vents? No. That won't make the pt comfortable.
The doctor needs called. Likely the pt can be treated without being uprooted if he is in the final stages.
Fluid in the lungs is very very common in later stages.
However fever and pain is plenty of reason to treat. O2 will not shirt this pt whether his SATs are fine or not . This is a case where o2 can be applied for comfort.

I'm getting tired and not making Much sense.

The nurse called, you are now the patients advocate. If he doesn't seem to want or tolerate transport, call the doctor or request nurse does.
I know from experience they are less hesitant to call in an antibiotic or whatever in the late stage of life and would much rather let the pt rest at home if he or she so desires. Yes, I spent 24/7 with a hospice patient minus shower time . The doctors and nurses will do anything to keep patients at home and comfortable. Even sending people to get blood drawn. Sending courioirs with meds etc. The only things that can't be don't here is an x ray
 
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DNR does not mean "do not treat", but typically hospice patients are nearing death and only want comfort measures. That's why they are in hospice. Most of them also have their wishes pretty clearly spelled out in their advance directive.

Best thing to do here, as has been pointed out, is to talk to the wife about what the patient wants, if of course he can't communicate himself.

Probably the best thing for this patient is morphine. Enough to make him comfortable.
 
Having PNA which is not treated is not comfort. Many patients in hospice are not always "near death". Some patients go to hospice and still receive dialysis. Some are on high flow oxygen devices (the real high flow devices and not a nonrebreather mask). Some continue to wear their home CPAP or BiPAP devices. Some may go into the hospital for surgical procedures. Some may continue to talk about new treatments with their doctors. Some may go on rescue BIPAP in the hospital with a DNR. Some may be intubated with a ventilator and still have their DNR.

Being an advocate does not mean believing hospice equals imminent death. Be careful there because with holding treatment may also put you crossing the line to cause the death along with unnecessary suffering.
 
Clipper1 said:
Having PNA which is not treated is not comfort.
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With enough morphine it can be pretty comfortable, if that is what the patient wants.


Clipper1 said:
Being an advocate does not mean believing hospice equals imminent death.

Be careful there because with holding treatment may also put you crossing the line to cause the death along with unnecessary suffering.
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Which is exactly why I wrote:
Halothane said:
Best thing to do here, as has been pointed out, is to talk to the wife about what the patient wants, if of course he can't communicate himself.
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and

Halothane said:
Most of them also have their wishes pretty clearly spelled out in their advance directive.
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I said nothing about witholding treatment, or that hospice necessarily means that death is imminent.
 
Clipper1 said:
Having PNA which is not treated is not comfort. Many patients in hospice are not always "near death". Some patients go to hospice and still receive dialysis. Some are on high flow oxygen devices (the real high flow devices and not a nonrebreather mask). Some continue to wear their home CPAP or BiPAP devices. Some may go into the hospital for surgical procedures. Some may continue to talk about new treatments with their doctors. Some may go on rescue BIPAP in the hospital with a DNR. Some may be intubated with a ventilator and still have their DNR.

Being an advocate does not mean believing hospice equals imminent death. Be careful there because with holding treatment may also put you crossing the line to cause the death along with unnecessary suffering.
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Nobody is talking about with holding treatment, only doing what the patient wants and keeping them comfortable. I said to advocate for the pt, no kill them. Why do you not pay attention?

Believe me. I know all about hospice, unfortunately . More than most.
Believe it or not, it does mean the end is near, the patient and the doctor have usually decided the patient has less than 6bmonths.
 
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