If you have a DNR/DNI....

[JR6ooo4]

I don't like the idea of that type of database. I am often confused with my dad since I am a JR. One time they were holding a plane for me! Since I (actualy my dad) had checked in, and now was not on the plane, they assumed the worst, for safety.

I would hate to think you need to check with a computer before saving a life! What if the internet is down?

It should be the responsibility of the relatives to notify the healthgivers. You have enough to worry about already.

Mikeeee

 

[Pea-n-Me]

I have a had time with that type of database. I am often confused with my dad since I am a JR. One time they were holding a plane for me!

I would hate to think you need to check with a computer before saving a life! What if the internet is down?

Good points, Mikeee. The name issue is HUGE! I know in my doctor's office there is someone else with not only the exact same name as me, but our birthdays are almost exactly the same as well - same year, but she's 10/9 and I'm 9/10. I always think that has disaster written all over it.

FYI we do have Failsafe computers throughout the hospital which work even when hospital systems are down.

 

[Piglets Mommy]

Okay a few answers.

1st, this patient is normally treated at a neighboring hospital. it just happens that our hospital is closer to his house- (by a few blocks).... he was in severe respiratory and cardiac distress, and therefore went to the closest trauma center...that was us

2nd- EMT's in both NH and VT are NOT to override a standing binding legal DNR document.

Scenario is- you ASK does the patient have a DNR - I'm an EMT as well so I know the drill. Anyone present can answer- if they HAVE the paper, we do not 'save' them. If they do NOT have the paper, yup we tube them...it's simple that way...however a database would solve this- because dispatch could access it..

this patient came in on CPAP, so the EMT's did not perform CPR...they assisted in non-invasive ventilatory support. They did perform life saving measures- because the deal is that now we look for cpap or i/epap to work before we actually intubate (if the time allows)

The patients family notifiied the ER doc 1.5 hours into the treatment, when he was going over medications and so forth with the wife and son. At that point, they said it. Our ER doc called the neighboring hospital and got a copy of it fax'd over.

Yes, at our hospital, until a DNR is written as an ORDER every single time the patient comes in, they are not DNR. Even if I know patient- and know they have a legal standing DNR, until the treating doc writes it as an order, I tube them.

It still sucks, I'm guessing he is still vented and i will see him tomorrow I'm sure when I'm doing vent checks etc... I just hope I'm not the one to extubate!

Now that he is intubated, we can NOT extubate him because of a DNR order, he would have to have no brain activity, etc.. basically be on full life support with no chance of recovery and the family would have to make that decission.....extubating end of life just plain sucks!

Brandy

So they actually have to physicaly have the paper in their possession?

I know that my parents both have living wills and don't want to be resussitated, but those papers are in their fire safe.... what if something happens and they are not at home??? Or I am too much of a wreck to remember the combination, right away, etc???

My first instinct would have been to call 911, but depending on the situation, i'm wondering if that's the right thing to do...not being a medical expert, I wouldn't know if someone was having a minor heart attack, or if it was something much more critical.

 

[mudnuri]

Not necessarily. DH's cousin had an acute illness at the age of 59 that resulted in him being intubated. While hospitalized they discovered that he had a huge metastatic ca. on his adrenal glands that had spread through his belly and invaded his spinal cord. It was inoperable. They attempted to wean him from the vent unsuccessfully. They removed a lot of the sedation during the process and explained his very dire situation to him. He made the decision with his family to be extubated. We went to visit him prior to the extubation and stayed with the family for a while afterward. They sedated him so he would not be uncomfortable and he died within 6 hours. Decisions are made to extubate patients every day. One doesn't need to be brain dead to make that decision.

Actually the question that was asked is- Do i now extubate BECAUSE Of the DNR order- and my answer is NO, I dont....its different with every situation- which you pointed out....in this situation- the family would have to make that decision- and due to the DNR that would NOT be enough of a reason....that was the point I was trying to make, not argue about how or why a vent can be discontinued.... trust me, I know those reasons

Brandy

 

[NotUrsula]

The name issue is HUGE! I know in my doctor's office there is someone else with not only the exact same name as me, but our birthdays are almost exactly the same as well - same year, but she's 10/9 and I'm 9/10.

Not to discount all of the other concerns, but as a person who has done a lot of database design, I can tell you that the name wouldn't matter, because that is not how the records would be designed, thanks to privacy laws. The way that it would have to be done would be to assign each record a unique ID code, and the code would be the access point to the record. For the best failsafes, the code should ideally be machine-readable, such as a RFID tag, and it should be permanently affixed to the person's body. We're talking implants here.

The implant would have NO info on it but the code; the person reading it would have to transmit the code to the database to get any info on the DNR. This kind of technology would also allow the patient to update the DNR or vacate it as they wish, again by using the code, backed up by a PIN for any edits. Retinal scan verification could be added as a third-level safeguard.

The technology exists to be able to set up a database of this type, but it would be very expensive to administer. Getting enough hospitals and Emergency services departments to buy into it would be the biggest problem I see.

 

[mudnuri]

So they actually have to physicaly have the paper in their possession?

I know that my parents both have living wills and don't want to be resussitated, but those papers are in their fire safe.... what if something happens and they are not at home??? Or I am too much of a wreck to remember the combination, right away, etc???

My first instinct would have been to call 911, but depending on the situation, i'm wondering if that's the right thing to do...not being a medical expert, I wouldn't know if someone was having a minor heart attack, or if it was something much more critical.

at the EMS level, yes, If you can't show me the legally binding document- I will perform CPR to the best of my ability... 100% of the time. Even if it's my family, WHO I KNOW has a DNR....if you can't show it to me, I dont' trust you...simple.....it's my medical license on the line...

I would suggest- keep a copy of it with your parents medication list on the fridge in there house....we need both to either help save you, or let you go if it's your time....

If you have the correct documents, for your states regulations, you can and should call 911. There is no reason a person should have to die in pain or agony because EMS was not called. A lot can be done to make the end of life comfortable

Brandy

 

[WendyKris]

DNR/DNIs are a terribly scary thing for a family. They often times do not quite understand what will happen with the patient at the end of life. It is not like tv, where the family gathers and says goodbye, it is often times scary, the patient may moan, breathing becomes irregular,etc. The family panics and calls 911.

In Massachusetts, the DNR form was changed 7-8 years ago, as was mentioned above. The form alluded to is called a Comfort Care DNR form and is filled out by the patient's physician. This has been a godsend here in Massachusetts. In the past, I would arrive at a residence, find someone in cardiac arrest, and was obligated to "work" the patient. EMT's in Massachusetts have a "duty to act". With the advent of the Comfort Care Form, our life, and that of the patient's became much simpler.

If we now arrive at a residence and the patient is in cardiac arrest, we are no longer obligated to work on the patient. We must see the form before that can happen, but in most cases, it is posted in an easily accessible area, such as the regridgerator or over the patients bed.

The only caveat to this form, is if a family member/guardian informs us that they are the health care proxy and would like the patient "coded". We are then obligated to work on the patient, due to the fact that we do not have time to verify the validity of their claim.

Although the advent of the Comfort Care Form has made the life of an EMS worker much easier, it ultimately comes down to family education.

Like the OP, I have worked codes on patients that did not want to be coded. It is very difficult on everyone, especially the patient, if they survive.

Sorry for the length of the post, but I was directly involved in the writing of the original Comfort Care Forms, and although it makes a huge difference in the lives of everyone involved, it sometimes is still frustrating.

 

[Cool-Beans]

No way I want computers controlling DNRs. Someone would end up dead because the computer said to DNR him when the paper didn't actually exist. And at some point a guy who had a DNR would be stuck on a vent because nobody knew he was a DNR.

I want the paper in the file.

It works okay now. Sometimes we code people who are DNRs but don't have the form, but better that than not coding someone who wan't a DNR. I don't even want to think about that.

Computerizing it would just screw it up so badly.

I'd much rather be sued for wrongful life than wrongful death. I'd sleep better, too.

 

[Piglets Mommy]

at the EMS level, yes, If you can't show me the legally binding document- I will perform CPR to the best of my ability... 100% of the time. Even if it's my family, WHO I KNOW has a DNR....if you can't show it to me, I dont' trust you...simple.....it's my medical license on the line...

I would suggest- keep a copy of it with your parents medication list on the fridge in there house....we need both to either help save you, or let you go if it's your time....

If you have the correct documents, for your states regulations, you can and should call 911. There is no reason a person should have to die in pain or agony because EMS was not called. A lot can be done to make the end of life comfortable

Brandy

Thanks for this info...I didn't realy think about the paperwork aspect until reading this thread. I will make sure I have copies of everything in my house and theirs!

 

[daisax]

Aside from putting it on the fridge or above the bed, if the person is mobile, keeping a copy in the car's glove compartment could pay off if you find yourself away from home.

Likewise, a close family member or neighbor could keep a copy in their car so it would be "handy" if the patient's own copy wasn't nearby.

God willing I have enough notice to make one, I'll probably decoupage my front door with DNR forms.

 

[Cool-Beans]

Family has the last say. Even if the patient has a DNR order, even if it is done correctly, the family can rescind it. I see it happen all the time and it sickens me.

Not in Ohio, they can't. If a person choses to DNR themselves, that's how it goes.

It is sometimes very frustrating and heartbreaking for the family to deal with, but the wishes of the patient must be respected. I think that is the way to do it. As hard as it is on the family, every person should get to make that decision for themselves.

 

[WendyKris]

The Comfort Care Form in Mass, has a tear off bracelet at the bottom that can be worn similar to a hospital bracelet. It makes it easier for the patient, and EMS....we don't have to look for the form, they are wearing it.

 

[scottishduffy]

In Florida family has the final say. A person can have the perfectly filled out DNR, filed properly with their attorney and whole deal. However, if the family does not want to enorce it than we don't. You not only need a DNR written out, but you need a designated health care proxy who is willing to enforce it for you.

I know many of my patients who had Do not rescucitate/ Do not intubate orders who are now ventilator and feeding tube dependent because family does not wish to let them go. It happens *ALL the time*. Most of the time the family will just take a few days to assess the situation, and then enforce the DNR and allow their loved one to go peacefully. Sometimes though a family refuses to let go even if someone is vegetative or terminal... It is sad. There have been several cases that really bothered me in this respect because the person's own wishes were not respected, and they lingered for months. It is hard for family to let go, but sometimes the greatest act of love you can do is to let a loved one pass.

 

[ZPT1022]

What most people don't realize is that the agency that accredits hospitals mandates that "code status" be addressed with every patient who comes to the hospital. Those that don't comply risk losing accreditation. So every patient who comes in is asked their desires, and we even have to offer them the paperwork to fill out directives if they don't already have them in place. However, with that said, for most people coming in to the hospital, it's not exactly an urgent issue unless someone is critically or terminally ill, when it becomes a little more pressing to know exactly what the patient desires.

My DR warned me about that when I was going in for endometriosis surgery. I decided to get a POA for DH and place it on file with all my DRs and the hospital. She really scared me with that, and honestly, at my age (late 20's), my thoughts on the matter are different depending on the scenario. This way they are obligated to talk to DH who knows my wishes.

We waited for my father-in-law to pass but were NEVER told who to call when he finally did. We called 911 of course which was totally NOT the thing to do..........but we've still never found out who we should have called.

So? Who do you call when someone dies? (I'm talking about an expected death, of course)


OP my heart goes out to you in situations like this. Tough tough choices and decisions for family and caregivers. A database would be a start.

Assuming it wasn't a hospice situation,I would have called the funeral home directly. They usually have someone answering phones 24/7.

 

[DawnCt1]

Assuming it wasn't a hospice situation,I would have called the funeral home directly. They usually have someone answering phones 24/7.

Unless it is a Hospice situation, calling the funeral home yourself may not be possible. The deceased must be pronounced dead. Most hospice RNs can do that in many states. They can in Ct. I believe at the time, DH pronounced my mom. It was such a stressful time, I can't remember who signed the death certificate, but I think it was DH.

 

[ZPT1022]

DNR/DNIs are a terribly scary thing for a family. They often times do not quite understand what will happen with the patient at the end of life. It is not like tv, where the family gathers and says goodbye, it is often times scary, the patient may moan, breathing becomes irregular,etc. The family panics and calls 911.

Funny you say this because the two times I've sat with dying family members I was shocked by how anticlimactic it was. I fully expected *something* to happen, prepared myself for it and both times the breathing just got slower, maybe a little raspy, but it just kind of stopped and that was it. Both times I was the person to check for pulse and found there wasn't one and that was that. Really a bizarre thing.

It is hard for family to let go, but sometimes the greatest act of love you can do is to let a loved one pass.

Amen to that. When my Mema was dying most everyone kept coming up to her and saying "Don't die on me" and "you can't go yet". I understand the sentiment but it really didn't help anything at all. Her sister and I were the only ones telling her "It's okay to let go, you've fought, you've been brave, it's over. Be done with it and you don't have to be in pain anymore" Does it suck to have to be the one to say that? YES! But my goodness, trying to keep someone hanging in there who really just doesn't have it in them anymore is cruel.

 

[ZPT1022]

Unless it is a Hospice situation, calling the funeral home yourself may not be possible. The deceased must be pronounced dead. Most hospice RNs can do that in many states. They can in Ct. I believe at the time, DH pronounced my mom. It was such a stressful time, I can't remember who signed the death certificate, but I think it was DH.

At the very least the funeral home would know who to contact.

 

[arminnie]

My dad used to half kiddingly say that he was going to have DNR tattooed on his chest

Just a couple of hours ago I told my sister that I was going to have "no feeding tube" tatooed on my stomach.

My aunt died last night (age 87). She had been in a nursing home for 3 years - after being very debilitated by several strokes. She was so very, very unhappy and was ready to go. She quit eating. Her children were going to have a feeding tube put in against her wishes. I think that would have been incredibly cruel. They are not bad people, but just seemed so unwilling to let go.

Sometimes it is just time to let a person go. I lost my mother 10 years ago. I still miss her, but especially the last 48 hours of her life I was praying for her to be released.

 

[DawnCt1]

At the very least the funeral home would know who to contact.

I would call the patient's physician or who ever was on call for him, and they could better direct you.

 

[Judy from Boise]

States are very different....here in Idaho, you can just call the funeral home, their obligated to inform the coroner if the death meets certain criteria if not, it's a done deal.
Idaho has also had the EMS comfort one program(including the bracelet) for almost a decade.It allows comfort measures only to be provided in the home.