Saturday, February 11, 2006

End-of-Life Questions Strike Again

One of my most beloved patients is struggling with a recurrence of cancer that is giving him and his wife (and the entire care team) a run for their money. While I strive to keep him comfortable and at home, with as few horrible symptoms as possible, his current palliative chemo regimen is a major challenge. After managing to have him urgently evaluated this week for a fever and dehydration, it turned out that his white blood cell (WBC) count was so low that a virulent infection had raced through his blood and challenged his ability to survive. Before he lapsed into semi-consciousness, he and his wife signed a DNR (Do Not Resuscitate) order so that, in the case of cardiac or respiratory arrest, he would not receive the violent compressions of CPR or other heroic attempts to save him.

The evening of his admission to the hospital, the patient's wife received a late-night call from the attending oncologist who said that the patient's blood pressure was almost non-existent and they could not give him medication (vasopressors) to raise it as he was a "DNR" and raising the BP with meds would be considered a form of resuscitation(!). Needless to say, she was shocked, and the doctor agreed to administer fluids which might increase the blood volume enough to raise the pressure to a level supportive of life. Luckily, the fluids worked and he lived through the night, but the issue of what "DNR" really means was raised.

The next morning, when I learned of these calls to my patient's wife and heard that medications had not been used due to his DNR status, I was non-plussed, and immediately contacted the primary physician, who could also not believe what he was hearing. When I finally made it to the hospital, I met with two residents working under the oncologist who made the original call to the wife, and they reiterated that giving vasopressors was considered a form of resuscitation. I argued that this was not within the generally accepted definition of DNR orders, but they insisted on their position and I urged the primary physician to bring this issue to the head of oncology as soon as possible.

Decisions regarding end-of-life care are difficult enough, but when nuances like those described above are not fully communicated to the family---or agreed upon by members of the medical and nursing teams---trouble is afoot. I acknowledge that the oncology team may very well be technically correct in their assertions, but that does not preclude the fact that most individuals and families who choose a DNR order do not know exactly what they are signing for. From this experience, I suggest to anyone considering signing such an order, make sure you also have a living will or other document stating exactly what your express wishes are, including CPR, intubation, IV fluids, antibiotics, and other treatments encountered during serious and critical illness.

I will make sure that this issue is revisited ad nauseum within my workplace until we can identify the facts of the matter. For my part, I'm thrilled that my patient lived through that night, and that the conversation regarding what consituted proper care for him under the circumstances was not conducted post-humously.


Melaina RN, PHN, MS, CNS, ACHPN said...

In my medical center, like yours, vasopressors are considered resuscitation. I am impressed that your patient responded to vasopressors alone. I've had several patients who were DNR/DNI but "positive for pressors," meaning they would want this intervention done to resuscitate them. In my experience, however, my patients who were crashing to the degree that vasopressors were necessary - none of them have survived, even with the vasopressors. So your story is very inspiring to me! I think that a full DNR/DNI is more of a wish to "let me die peacefully and naturally." The times when vasopressors have been used, the deaths have been a lot more "high energy" as people rushed around trying to keep the patient alive. I think there is a distinct difference between these two desires and I'm not sure I'd agree that a full DNR/DNI should not include vasopressors, but I agree wholeheartedly that each component of the DNR should be explained to the patient and they should be permitted to accept or decline each mode of resuscitation. Our DNR/DNI forms delineate each intervention that the patient may accept or refuse.

Keith "Nurse Keith" Carlson, RN, BSN, NC-BC said...

Thanks for the reply, Mia. Actually, I think he did not receive any pressors at all, just loads of fluids to increase blood volume and thus his BP. Your reply is helpful and I will raise the issue at our facility. If someone signs a DNR order, it really should be delineated what they are agreeing to have done (or not done). Thanks so much for your help!

Unknown said...

I would think that at DNR order means do not resusitate if the patient actually stops breathing or has no heartbeat.. It doesn't mean to me that one should do nothing to prevent that from happening unless one is in a hospice/endstage condition.. It's a very difficult line to balance on.. One should definitely understand what one is signing. I think the forms should be much more elaborate and include scenarios for the patient to consider. Great post!!

Keith "Nurse Keith" Carlson, RN, BSN, NC-BC said...

It seems to be a facility-specific issue. I plan to bring it up to the risk management department at the hospital. Thanks for commenting.