DNR Does Not Mean No Care

Lorraine Fields, MSN, CNS

Disclosures

J Neurosci Nurs. 2007;39(5):294-296. 

In This Article

Palliative Care

When a patient is admitted to a palliative care center, a DNR Comfort Care Only status is initiated (Summa Health Systems, 2006). Nursing orders may include allowing family 24-hour visitation and discontinuing all invasive monitoring, nasogastric tubes, laboratory testing, and central venous access catheters, while leaving one venous access for administration of intravenous (IV) medications. All medications are stopped that are not directed toward the goal of comfort. The primary nurse is responsible for ensuring the patient has been off of neuromuscular blocking drugs for more than 24 hours to prevent any question of impropriety when discontinuing the ventilator.

Ideally, medications and sedation are ordered and given prior to extubation. Glycopyrrolate (Robinul) 0.2 mg IV can be given 15 minutes prior to extubation to decrease congestion and secretions. In addition, it can be given IV every 4 hours if secretions continue to be a problem or if the patient has labored breathing. A bolus of morphine sulfate (2-10 mg) can be given at the same time as the glycopyrrolate prior to extubation to dry up secretions and dilate cardiac and pulmonary arteries, making breathing easier. The dose of morphine is prescribed in a range so nurses can determine how much is needed by the patient's symptoms, age, or size. If the patient is unable to tolerate morphine, a fentanyl drip can be substituted. In addition to the bolus dose, a continuous morphine infusion can be started at 4 mg/hr with bolus dosing every 15 minutes to an hourly rate to control symptoms of pain, respiratory distress, agitation, anxiety, or to maintain a respiratory rate under 24 breaths a minute. Nurses should document the response of the patient to every opioid dose change. If the dosing regimen fails to achieve patient comfort or is unable to maintain the respiratory rate under 24 breaths a minute, the opioid drip may be increased by 25% of the existing hourly rate every 15 minutes as needed, up to 100% of the existing hourly rate per hour based on the patient comfort level. In addition, adjunct drugs such as acetaminophen can be given orally or rectally for temperature control. Haloperidol 2-5 mg IV every 1-2 hours, as needed, is used for confusion, delirium, or agitation; a lower dose of 0.5-2 mg may be used in the elderly with caution.

Once the patient appears comfortable, is premedicated, and the opiate drip is in place, the physician can choose either a gradual or immediate wean from the ventilator (Truoug et al., 2001). If a gradual wean is chosen, 15 minutes after the opiate or sedation dosing regimen has been initiated the ventilator is switched to intermittent mandatory ventilation (IMV) and pressure support and positive end-expiratory pressure is turned off. If the respiratory rate is under 24 breaths a minute, the IMV is weaned to 4 breaths per minute over 10-60 minutes while titrating the opiate or sedation dose as indicated for comfort. If the respiratory rate is more than 24 breaths per minute, the nurse increases the drug regimen or calls the physician. When the patient appears comfortable at the IMV rate of 4, the patient is extubated and remains on room air. If the family requests, oxygen can be administered at 2-4 L per nasal cannula.

An immediate wean is instituted 15 minutes after the opioid or sedation dosing regimen has been initiated, when the patient appears comfortable. The patient is removed from the ventilator and then extubated. Oxygen is not generally applied, but can be for family comfort.

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