What Does a 'Do Not Resuscitate' Order Include?

[MicahW]

This is a two part question:
a) Can a person with a DNR be given Adenosine, for example, if they are in SVT, or CPAP for a pulmonary edema? I get that a person with cancer, for example, would not want to be resuscitated just to live for another week in pain; however, I doubt that if I had a pulmonary edema or something, I would want to suffer through that.
b) I a patient has a valid DNR bracelet on but asks you to help them beyond what a DNR would allow, how should you play it? I have always thought that I would have them rip the bracelet off (which would mak it invalid) or something but I really don't know.

 

[MicahW]

I posted this in scenarios because of the second part of the question, but I now realize that it probably belongs somewhere else. If anyone knows how to move it, please let me know.

 

[luke_31]

A patient with a DNR can revoke it at any time. If they ask you to do something that would invalidate the DNR you can do it.

 

[Underoath87]

You seem to be confusing resuscitation and treatment. A DNR shouldn't really come into play until the patient's heart stops beating. However, we usually forgo intubation/BVM in respiratory arrest, since we're just delaying the inevitable if the respiratory arrest was in any way related to the patient's terminal illness, as opposed to an easily reversible cause.

 

[systemet]

These are difficult questions to answer. You might want to have a discussion with your supervisor or medical director to clarify exactly what is allowed by statute in your area. The most black-and-white interpretation of the DNR is that it only comes into play when the patient is pulseless, and until that point full ACLS is initiated, if an ambulance is called.

I'm fortunate, my province allows for patients to write detailed instructions about what care they would want to have should they lose capacity or become unconscious. We also have a fairly robust "Goals of Care Designation" system, that directs what a healthcare provider is allowed to do in a given situation. There's an example here, http://www.palliative.org/newpc/_pd...materials/2011 EPCC_Advance Care Planning.pdf . Page 10 shows a matrix of designations. This allows a patient to designate whether they'd like resuscitation and ICU care or not, and if ICU care / Resuscitation is to be initiated, whether the patient would like intubation, or CPR. It also allows for designations for palliative patients where they can specify that they don't want to be transported to the ER.

 

[systemet]

Just to answer the questions:

(a) Straight DNR - yes. Depending on the laws in your region, it might be a good idea to have a quick discussion about what the patient would like done if the adenosine causes a cardiac arrest, and being very clear about this risk. CPAP - again, acceptable under a DNR, but it would also be worth having a discussion about the risk of CPAP failing, aspiration, and the patient's wishes regarding ICU admission / more aggressive therapy. If the patient's moribund, and there's no family available, your hand may be forced. This would not be a bad time to phone a friend and discuss your situation with a physician, if you need help.

(b) I'd check your local practice. We don't have DNR bracelets in my area, but I'm sure the local ER will clue in if the patient arrives intubated with dopamine or levo hung. I'm fairly confident that if you are going to get in trouble for initiating resuscitative measures, the arm band isn't going to matter.

This is all very location dependent. My impression has been that in the US there's often very strict rules regarding end-of-life care.

 

[phideux]

We don't have DNR bracelets. We need to have a valid signed DNR, in our possession for it to be valid. That said, like Underoath87 stated, there is a difference between resuscitation and treatment. If they are in SVT, conscious and need a shot of adenosine, fine, maybe even a cardioversion if the Adenosine didn't work, that's treatment. Respiratory issues where they can benefit from CPAP, sure that's treatment. Unconscious, unresponsive, pulse-less, no CPR, no drugs, no shock, that falls under resuscitation. Agonal/no respiration, in arrest or a lethal dysrhythmia, not dropping a tube in that one.

 

[Underoath87]

I've only seen purple DNR wrist bands used in hospitals. But the band itself is just a notice that the pt has a DNR in their chart, and has no value of its own.
And OP, be mindful that the DNR band may just connote that they pt has an in-hospital DNR, which is not applicable once they leave the hospital. You need a communal DNR after that.

 

[DesertMedic66]

Once again it's area dependent. We have the DNR bracelet here. It looks pretty much like a medical alert bracelet. All we need is the bracelet, we don't need the actual DNR paperwork.

 

[systemet]

Out of curiosity, how common is it in the US to be called to a palliative care patient, provide some medication, e.g. dilaudid, haldol, maxeran, scopolamine, etc., and leave them on scene?

 

[TransportJockey]

Out of curiosity, how common is it in the US to be called to a palliative care patient, provide some medication, e.g. dilaudid, haldol, maxeran, scopolamine, etc., and leave them on scene?

Not very. Home hospice nurses usually provide that. Hospice is, thankfully, becoming more common and well regarded.

 

[NTXFF]

We've got DNR bracelets, papers, and even tattoo's. I was told from day one DNR doesn't stand for Do Nothing Right now. In Texas it limits typical resuscitation efforts ie. intubation, compressions, meds... There are also DNR's here that may be compression only etc. I think the majority of it is state and protocol dependent. I've put CPAP on or bagged several people who have DNR's. I've also had family and the pt themselves revoke it. It's a slippery slope.

 

[cruiseforever]

These are difficult questions to answer. You might want to have a discussion with your supervisor or medical director to clarify exactly what is allowed by statute in your area. The most black-and-white interpretation of the DNR is that it only comes into play when the patient is pulseless, and until that point full ACLS is initiated, if an ambulance is called.

I'm fortunate, my province allows for patients to write detailed instructions about what care they would want to have should they lose capacity or become unconscious. We also have a fairly robust "Goals of Care Designation" system, that directs what a healthcare provider is allowed to do in a given situation. There's an example here, http://www.palliative.org/newpc/_pdfs/education/2011conferencematerials/2011 EPCC_Advance Care Planning.pdf . Page 10 shows a matrix of designations. This allows a patient to designate whether they'd like resuscitation and ICU care or not, and if ICU care / Resuscitation is to be initiated, whether the patient would like intubation, or CPR. It also allows for designations for palliative patients where they can specify that they don't want to be transported to the ER.

Some states are starting to use the POLST form. It allows the patient and MD to list what they would like done.

http://www.polst.org/about-the-national-polst-paradigm/what-is-polst/