Put yourself in the patient’s’ family’s shoes, if your mom were clinically decompensating before your eyes within seconds, would you have the capacity to make a decision right then and there?
A do not resuscitate, more commonly known as DNR, is a provision meaning that if your patient’s heart were to stop, that you will not resuscitate them (not performing CPR to try and bring them back).
“When DNR order discussions do occur, they frequently occur too late. A study of 500 patients who suffered from a cardiac arrest showed that 76% of these patients with DNR orders were incapacitated to make decisions at the time a DNR order was discussed. However, only 11% were impaired at the time of admission. Only 22% of patients participated in the decision about their DNR order. The majority of DNR orders were written within 2 to 3 days before death”(Yuen, J.K., Reid, M.C. & Fetters, M.D., 2011).
The key here is knowing what your patient and their loved one’s wishes are. I’ve seen this scenario so many times, where family isn’t sure what to do. That decision becomes even more difficult when the patient’s clinical status worsens. Don’t get me wrong, many can make that decision, but it’s overwhelming. They then decide to proceed with CPR (Cardiopulmonary resuscitation) and intubation (life support for airway management), just because they can’t think straight.
Knowing whether or not your patients want someone pounding on their chest to revive them has a HUGE impact, especially if there would be no improvement in quality of life.
Signing a DNR form, does NOT mean that anyone is giving up, EVER! It means that the patient has an advocate that knows EXACTLY what is wanted.
As the nurse you should not give your opinion to sway a decision, such as,”If this were my mother, I would do this..” It is not our role to tell them what decision to make. You stay with them, hold the family member’s hand and talk about everything and anything that they need support in. The one thing that you should do, is tell them the TRUTH. I cannot count, how many times I’ve had a family member ask me to tell them to not sugar coat anything. I just take them aside and say exactly what is going on, whether it’s an improvement or the opposite.
Just because you’ve signed a DNR, it doesn’t mean that they are actively dying or that treatment is going to stop. Family members have walked up to me and were frank about it, asking if their family member is a DNR. Does this mean that their loved one gets taken care of less? Does this mean that they immediately prepare them for organ donation? ABSOLUTELY NOT! Everyone gets equal treatment. No one is less than the other. It just means that we know their wishes as their healthcare providers. Organ donation should not even be part of a discussion from the bedside team at this point, unless a family member inquires about it. It only arises when the patient is actively dying. Each state in the US has an organ donation network who take over, if the patient is a candidate.
This is an incredibly sensitive topic and doesn’t happen enough. As nurses, we have to be an advocate and have this discussion upon admission/arrival to the hospital. The provider does not need to start this conversation. It can start with US. If you feel that it is difficult then it can be a team effort, but as you take care of someone that is inpatient in a hospital, their CODE status is incredibly important to know.
YES, a living will is different from a signed DNR. I’ve come across this question a lot in the past couple weeks. If your patient has a typed up living will, this does not mean that they are automatically a DNR. Read the documentation and go over it with the patient and the healthcare proxy. If they say that they do not want to be resuscitated, bring a PA/NP/MD into the room right away as a witness, the order is then put in the computer. In NY, you do not need a paper signed by the patient for a DNR. So please, make sure you know what is allowed in your state before you bring a paper into a grieving family’s room to sign.
A living will has the patient’s wishes stated of how they would like to be treated if their medical status were to worsen such as wanting antibiotics, a PEG tube for feeds or to be intubated, but is NOT a DNR. A living will is when a patient becomes incapacitated and would want the support of artificial means to keep them alive. Remember, you are advocating for your patient. So many people have had CPR performed on them when a code status was unknown and then come to find out that they were a DNR. It’s upsetting and unfortunate.
Nursing changes our perceptions. Going into nursing I didn’t know if I wanted to be an organ donor or someone who would want to be resuscitated in certain circumstances. Now as a seasoned nurse, now an NP, my view has drastically changed. I also know who my healthcare proxy (my big sis!!) and that I would not want to be kept alive if i did not have a good quality of life. Everyone’s decision is their own, there is no right and wrong.
Communication is the most important factor in this entire process of knowing what our patients want. Explain, educate and communicate. We are their advocate as nurses and we value each and every person’s choice.
Yuen, J.K., Reid, M.C. & Fetters, M.D. J GEN INTERN MED (2011) 26: 791. https://doi.org/10.1007/s11606-011-1632-x