DNR Does Not Mean No Care

Lorraine Fields, MSN, CNS

Disclosures

J Neurosci Nurs. 2007;39(5):294-296. 

In This Article

Abstract and Introduction

End-of-life care is a complicated topic, especially in a neurological intensive care unit. Death is a daily part of nursing care and should be treated with respect and a definite plan of care. Unfortunately, there are still hospitals that do not have protocols to deal with this outcome. The administration of opioids and appropriate sedation can be the difference between a calm serene death or one that is fraught with dyspnea, struggling, and unhappy families. Every hospital should have palliative care and hospice planning. This case study is about a dying patient that did not receive palliative care appropriately; however, through determination and personal knowledge of death and dying, a neurosurgical nurse was able to change the way a hospital dealt with do-not-resuscitate patients. Do not resuscitate does not mean no care; it means a different kind of care that can best be achieved through end-of-life protocols and education.

A 73-year-old Caucasian woman was brought into a community hospital emergency department (ED) intubated and ventilated after a cardiac arrest. The paramedics stated that she was playing bingo at the local senior citizen community center when she fell face forward. By the time the paramedics arrived and defibrillated her five times, she had gone without oxygen for approximately 15 minutes. On arrival at the ED, she was pink with an oxygen saturation (SaO2) of 98% and had no spontaneous breathing. In addition, her cardiac rhythm was sinus tachycardia at a rate of 150 beats per minute and her blood pressure was 100/60 mm Hg. A lidocaine drip was in place, and a large hematoma noted on her right forehead was oozing sanguineous fluid. She was admitted to the intensive care unit (ICU) with a diagnosis of cardiopulmonary arrest and secondary diagnoses of traumatic brain injury, chronic obstructive pulmonary disease, coronary artery disease, valve dysfunction, congestive heart failure, tobacco abuse, and atrial fibrillation. A list of current medications obtained from her daughter by telephone included digoxin, warfarin, verapamil, amlodipine, estrogen, an H2 blocker, and an albuterol and ipratropium inhaler; she had no known allergies.

Her daughter was unable to get to the hospital for 12 hours, and upon arrival found her mother seizing, intubated, and unresponsive to pain. The patient had a written Do Not Resuscitate (DNR) form, as well as a living will, and had made it clear to her physician, family, and friends that living without her full cerebral faculties in a nursing home was to be avoided at all costs. Her living will even contained stipulations of what to do in case of anoxic brain injury and stated that intubation and maintenance on a ventilator was to be avoided.

The patient seized for more than 24 hours, until the cardiologist finally turned off the lidocaine drip. The patient's neurological status remained unchanged over the next 48 hours, with only a gag reflex, no response to pain, and continued seizures. The family physician informed the daughter that the patient's anoxic brain injury would not have a favorable outcome, so a DNR order was written along with orders to take the patient off the ventilator. This small community hospital had no terminal wean or palliative care protocols. At this particular hospital, policy mandated that a second physician had to be consulted about removing a patient from the ventilator, and unfortunately the cardiologist and pulmonologist refused consultation. Instead, the daughter was accused of trying to "euthanize" her mother. The critical care nurses rallied around the family, and to the umbrage of the specialists, suggested an opinion from a neurologist. According to Gajewska, Schroeder, De Marre, and Vincent (2004), this represents typical behavior for ICU nurses, as they more frequently advocate for early termination and comfort measures than physicians. The family physician was called by the nurses, and after much pressure, agreed to consult a neurologist. The neurologist came to evaluate the patient that afternoon. After a full neurologic examination, the neurologist met with the family and agreed with the family physician that the patient would not recover from the anoxic injury with any reasonable quality of life. The neurologist agreed to extubate the patient and transfer her to a medical surgical unit. Unfortunately, after being transferred, the patient languished for several more days on the medical surgical unit without the benefit of palliative or hospice care. The daughter tried desperately to advocate for her mother and have her transferred to another facility. A hospice center finally had an available bed by the third day; the patient was transferred and expired 1 hour later.

An alternative to this unfortunate incident would have been to admit the patient to a palliative care unit, which could have helped with the transition from aggressive care to comfort care with an emphasis not on giving up, but rather, on helping everyone to accept the inevitable. The World Health Organization (WHO) defines palliative care as "an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" (2006). This patient was obviously uncomfortable with continuous seizure activity, as well as tachypnea and coughing while on and off the ventilator. A palliative care center, or even reasonable palliative care protocols, would have been appropriate for this patient because the staff members would have made the patient comfortable, removed unneeded equipment (e.g., the ventilator) more quickly, and given the family much needed support. In addition, when the time came, the patient could have been effortlessly moved into a hospice for end-of-life care.

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