If you have a DNR/DNI....

[mudnuri]

I had a really bothersome time yesterday...

Had a code come into the ER, older man, cardiac arrest...he arrived and his hr was 40, RR about 4, bp 60/40...

The Wife called EMS....The son (early 30's) was also present.

EMS rolled in pt was still breathing on his own, though on CPAP...we ended up having to perform CPR on the guy, and then intubating him...he is now in ICU on a vent, with no respiratory drive, no spontaneous breaths...

2 hours later, it becomes known via the family that he has a DNR...legal binding DNR order. done correctly...no question about it.

Now, I know why the family didnt tell EMS- they weren't ready for him to die. Selfish....he is ready, he has aortic stenosis, and is going to die...he also has CHF, and COPD...yes, he is going to die, he is 78 years old...he is going to die.

but this time, he may not, because we performed CPR and intubated him...he is now living on a vent

Why, in this day and age of technology do we not have a DNR/DNI database that is accessable to all hospital's? If you fill out a DNR/DNI, and its the legal document, why cant someone come up with a searchable database that would alert the ER staff to this? He comes in, the ER secretary enters his name/dob/ssn and BOOM...DNR flashes on the screen...seems simple to me!

I guess my point is- you might have a DNR and your family may know it, but are they okay with it? At times like these, you family may not be ready to let you go....and if they dont say anything, you will be resuscitated, you will be intubated and you will be put on a vent....thats the medical way. I will tube you, because that is my job.

And now, we will extubate him, generally folks are very happy when they are extubated, but I wonder what the look will be in this guys eyes when he realizes that not only did I extubate him, I also saved him....

Im having a really hard time with this one and normally I don't. I've had codes come in and worked on them for awhile and had them called, Ive had people not make it, even after intubation and ventilation...but this one really bothers me

Brandy

 

[Todd&Copper]

I have wondered the same thing - why is there no DNR database for hospitals? Situations like the one you just found yourself in are frustrating and sad. He made his decision, and he shouldn't have to carry around the paperwork with him all fo the time or wear a medical ID bracelet that say "I have a DNR". And what if a family doesn't know?

 

[Minnesota!]

I had a really bothersome time yesterday...

Had a code come into the ER, older man, cardiac arrest...he arrived and his hr was 40, RR about 4, bp 60/40...

The Wife called EMS....The son (early 30's) was also present.

EMS rolled in pt was still breathing on his own, though on CPAP...we ended up having to perform CPR on the guy, and then intubating him...he is now in ICU on a vent, with no respiratory drive, no spontaneous breaths...

2 hours later, it becomes known via the family that he has a DNR...legal binding DNR order. done correctly...no question about it.

Now, I know why the family didnt tell EMS- they weren't ready for him to die. Selfish....he is ready, he has aortic stenosis, and is going to die...he also has CHF, and COPD...yes, he is going to die, he is 78 years old...he is going to die.

but this time, he may not, because we performed CPR and intubated him...he is now living on a vent

Why, in this day and age of technology do we not have a DNR/DNI database that is accessable to all hospital's? If you fill out a DNR/DNI, and its the legal document, why cant someone come up with a searchable database that would alert the ER staff to this? He comes in, the ER secretary enters his name/dob/ssn and BOOM...DNR flashes on the screen...seems simple to me!

I guess my point is- you might have a DNR and your family may know it, but are they okay with it? At times like these, you family may not be ready to let you go....and if they dont say anything, you will be resuscitated, you will be intubated and you will be put on a vent....thats the medical way. I will tube you, because that is my job.

And now, we will extubate him, generally folks are very happy when they are extubated, but I wonder what the look will be in this guys eyes when he realizes that not only did I extubate him, I also saved him....

Im having a really hard time with this one and normally I don't. I've had codes come in and worked on them for awhile and had them called, Ive had people not make it, even after intubation and ventilation...but this one really bothers me

Brandy

it has to be a very tough job - thank you for doing it.

I agree - a searchable DNR database would be wonderful!

 

[mickeyboat]

Brandy. I can't imagine.

The problem with all of these end of life directives is that basically they are only as good as the family members who are willing to "enforce" them. I suppose it would be a privacy vioation to disseminate that kind of information via a nation-wide database, but patients need to really understand that if the treating hospital does not have record of the order, it cannot be enforced over the wishes of family. People also need to make family aware of their strong desires.

It kind of surprises me that the hospital did not have record of the DNR. I was under the impression that those don't happen until someone is pretty close to the decision whether or not to use one. Had he been treated there before?

I'm rambling. Sorry you had to go through that.

Denae

 

[storzo]

Just curious, I really don't know....do the EMS/ER ask the family or do they have to step up and say it? If they have to step up maybe they just weren't thinking straight. If they are asked and lie, does anything happen? I know it's not perjury, but is there any penalty. And once they're on the vent and you find out about the DNR can you remove them?

Sorry for all the questions, but I am curious. My mom had a DNR but the doctor and the hospital were well aware of it and I was never asked to make any decisions. I am thankful to her for that.

 

[DawnCt1]

I think the situation is, if EMS is called, they have to initiate life saving measures. They cannot take the word of a family member that the person is a DNR. If the family knows that there is a valid DNR and allows the patient to die at home, then that is okay, but once they pick up the phone and dial 911, the full response can be expected. My mom passed away at home. She was DNR because her condition was hopeless. On the day that she was passing, the hospice RN stayed with us. I think in part to discourage me from calling 911 if I had a sudden change of heart. She told me that if I called 911, we would not be able to 'control' the situation. Perhaps the family in this situation saw him fall acutely ill and panicked, dialing 911.

 

[mickeyboat]

I think the situation is, if EMS is called, they have to initiate life saving measures. They cannot take the word of a family member that the person is a DNR. If the family knows that there is a valid DNR and allows the patient to die at home, then that is okay, but once they pick up the phone and dial 911, the full response can be expected. My mom passed away at home. She was DNR because her condition was hopeless. On the day that she was passing, the hospice RN stayed with us. I think in part to discourage me from calling 911 if I had a sudden change of heart. She told me that if I called 911, we would not be able to 'control' the situation. Perhaps the family in this situation saw him fall acutely ill and panicked, dialing 911.

I have heard of this before, too, Dawn.

Denae

 

[chris1gill]

I'm sorry you're in such a pickle... you were doing your job, you weren't given the information, you can't go back. However, in Massachusetts, even with a DNR, it does not apply to EMT's if they are called. There is a separate form that must be filled out that is a State supplied form. It must be signed off by your doctor.... so, EMT's essentially override the DNR and they could face the very same scenario as you have, and I'm sure they do... since most people don't realize the DNR doesn't apply to Emt's in MASS.... we just went through this a couple of months ago.... But there IS a separate form to be filled out, that would prevent EMT's from resuscitating a patient.

But, whatever happens, you did your job, you did a good job, it's up to his family to explain their actions

 

[shortbun]

Dawn's right. When my aunt was dying, she had DNR copies posted on both doors, her bathroom mirror, in her kitchen and in her bedroom because her home health care people kept calling 911(against family requests) and the EMS folks would come. Twice, they resuscitated her. Once was after the copies of the DNR went up all over the house. After that, she agreed to leave her home and come to a beautiful little nursing home near me. She then had family and hospice with her at all times and was never resuscitated again.

 

[malibuconlee]

That's a tough one.

I worked in Medical Records for a year and the way things are now I'm not sure how a nationwide database would work.

I don't know how it worked in the ER, but the hospital I worked at if a patient was admitted with a DNR a copy of the paperwork had to be with the chart and the doctor had to SIGN AN ORDER for the DNR.

 

[NMAmy]

I wish there were a database, too.

My dad used to half kiddingly say that he was going to have DNR tattooed on his chest after my grandmother was resucistated against her wishes. When he had a stroke, he made me write it on a piece of cardboard and tape it to the head of his bed in the ER in case my mom and I were out of the room when something happened.

I wonder if the family, in their distress, just didn't realize what was going on until he was already intubated.

 

[MELSMICE]

It is too bad there is not a database or something. When did the family inform the hospital that he had a DNR order?

 

[Acklander]

The problem I would have with a national data base is, if there was an error. Let's face it, sometimes mistakes happen, we're all human. I'd hate to be brought to the ER and something come up in my chart saying DNR when that wasn't my intentions.

 

[yeartolate]

The problem I would have with a national data base is, if there was an error. Let's face it, sometimes mistakes happen, we're all human. I'd hate to be brought to the ER and something come up in my chart saying DNR when that wasn't my intentions.

I have the same issues. Too much chance for error (for now)

Best thing is education and resources. IF a family feels lost and does not have adequate medical back up, when the time arrives, they think they are doing the right thing. THey need to have ready contact with the MD so they know what to do. If they are not hospice and are dying and need the hospital (perhaps for pain issues) that can be handled without calling 911. But if the family does not have ready access they panic. I have been a critical care RN for 25 years - and I can say that if it was my family, I might panic as well without proper support.

Hospice can certainly bridge this gap, but realistically, hospice patients account for a very small percentage of the patients who do not wish to be "saved" in the case of a medical emergency.

But to the original OP, I understand your pain. Happens too often.

 

[DawnCt1]

I have the same issues. Too much chance for error (for now)
I have been a critical care RN for 25 years - and I can say that if it was my family, I might panic as well without proper support.

As a family member, daughter in my case, it is hard to "let go". Even if there is no quality of life and you aren't doing the patient any favors to be sure, family members do need support to do the right thing.

 

[Jpgirl]

I feel for you. Something very similar happened to my FIL. My MIL with held that info too. The rest of the family was furious knowing that FIL would not want to live like that. He slipped into a coma. I can't remember the timing but about 3 weeks passed. This woman would not let him go. Finally the doctors called a family meeting to persuade MIL to disconnect life support. Now don't you know on that very day during the meeting-FIL came out of the coma and his life signs improved??!!! He actually lived another 4 years . Of course he still had CHF-no cure for that, but they were viable years for him.
I'm a HUGE believer in DNR and respecting the patient's wishes, but sometimes God has different plans. Mil died about a year later of CHF and there was a reconcilliation between dh and his father and we enjoyed a very close relationship for the last 3 years he was here. I know it's tough for you but I'm just saying.......

 

[Mouse House Mama]

I want to thank you for your job. It surely isn't an easy one. My Mom told me a few years back that she was going to have a living will made up/DNR. Thankfully she is in excellent health but she wanted to make sure that if something ever did happen we would not have to male any decisions. Well they only work if you give the responders/doctors the paperwork. I told her that she better tattoo it on her forehead because I would never give them the papers. Call me selfish but that's how I feel.

 

[Pea-n-Me]

I work "upstairs" in the hospital, and it's not always clear even there, especially in the moments when someone's newly admitted and their code status is unclear. And when it's unclear, you have to go with resuscitation.

To complicate matters, when a patient who is DNR/DNI goes for an operative procedure, the DNR/DNI needs to be "reversed" temporarily.

There are other situations in which the resusciation orders get murky, such as during transporation to other facilities. We've had people have to stay in house until those issues can be sorted out, and sometimes it gets very compicated.

In this situation, I'd have to ask, what did the family expect by calling 911? "Helping" the person, of course. The EMS people can't be expected to decide in those few seconds whether this person should or shouldn't be resuscitated, they have to rescusciate if they're called. The better solution here would have been for the family to understand the patient's desires and leave him alone, ie "do not resusciate or intubate" if that's what he wanted. But that's very difficult for loved ones to do, especially when it's not "expected".

As for a national database, I don't know if it would be realistic since a person's wishes, and the orders themselves can change, and technology doesn't always keep up with those changes. The unthinkable would not resusciatating someone who should have been.

Keep up the good work, you did what you had to do. I know it gets upsetting sometimes.

 

[BMNABrinx]

Our family recently experienced the situation of a DNR order. My grandma was diagnosed with lymphoma on Dec. 7, 2007. I was fortunate to be the one who was taking her to all of her appts. and doing things for her. I knew her wishes as did her children. She absolutely did not want to be put on any machines. On Dec. 23rd, almost 1 week after her first chemo treatment, she became very, very ill. My uncle was with her at the time as well as a cousin who had been staying with grandma at night to help her. I was on the phone when they decided to call 911. Grandma was taken to the hospital and she never had to be revived so to speak. They did give her tons of medication to raise her blood pressure and fluids because she was severly dehydrated. She had developed an infection throughout her body. Her oncologist asked us at that time if grandma had a DNR. We had to say "yes" because it was her wish. Grandma was moved to CCU and was slowly improving until they put a purple bracelet on her left wrist. She asked what it was for and they told her it was "to let them know that if her heart stopped they weren't to restart it." That is when she took a turn for the worst and decided that she was going to die. She told me that evening that they said "my heart isn't strong enough to make it. I'm not gonna make it." The nurse told me she was very upset when he put the bracelet on her and explained it to her. He said if they had put it on her in the ER like they were supposed to instead of waiting 3 days that she wouldn't have even known it was there.
I do believe in upholding a loved ones wishes but I also think things need to be handled very delicately on the medical end in a case such as this. We did our part but what would have happened before the bracelet? It doesn't matter now though. Grandma went "home to see Jesus and grandpa" on Dec. 28 and she is no longer in pain.
I'm so sorry that you have to deal with things like this. It takes a very special person to walk in your shoes. Thank you for caring enough about people to make this your life.

 

[JimB.]

I think the situation is, if EMS is called, they have to initiate life saving measures.

Not necessarily true. I have gone on calls where the patient has had a DNR & I have not done any "life-saving" procedures, but only done "comfort" procedures (O2 via NRB & the like).

The PROBLEM arises when a patient has a valid, legal DNR & the family overrides it. They don't want to let mom/dad/grandma/grandpa/etc. go. It's against the patient's wishes & (IMHO) the wrong thing to do. But that's the "pickle" for us. We have to do what the family desires in that case (UNLESS the patient is still alert & properly oriented, than we follow the patients wishes.)

The bad thing about it is that a lot of times, the patient knows they are about to pass on, AND THEY DO NOT WANT TO DIE IN A FREAKIN" HOSPITAL!! Who can blame them? But the family is not prepared and does not know what to do. I know I'd rather be sitting on a chair on the porch watching birds or something else nice and peaceful.

That's where a good Hospice Program is a Godsend. These people are bloody well fantastic! Worth their weight in gold.

One short story - I went on a call a few years ago to a house for "unknown type medical emergency" (that's how about 65% of our call come out). Went to the house & found an obviously very sick man 1/2 on/off his bed. The family was present and very upset. Not frantic, but obviously emotionally drained & pretty much at their wit's end.

Turns out the guy is a terminally ill CA patient on Hospice care, but the hospice nurse had gotten stuck somewhere and was delayed getting to the house. I asked what they wanted us to do. The man's brother said "just make him comfortable as you can". We put him back on the bed, fluffed his pillows, covered him up & tucked him in so he was warm, put an O2 mask & cardiac monitor on him.

And watched him die.

But at least he was home with his family in a loving environment. We stayed until the Hospice nurse showed up & left the scene in her and the cop's care.

As was alluded to in earlier posts, sometimes the RIGHT thing to do is to do NOTHING. But it's hard & although I disagree with families at times, I understand their feelings & keep mine to myself.