DNR Does Not Mean No Care

Lorraine Fields, MSN, CNS


J Neurosci Nurs. 2007;39(5):294-296. 

In This Article

Nursing Role

Nurses must be actively involved in palliative care. Specific ways nurses can be involved include:

  • Providing meticulous care of the patient, including making sure the patient is kept clean and dry. Nurses can offer food, drinks, and a place to rest to the family and encourage them to take care of themselves during the dying process.

  • Contacting local hospice centers and nursing organizations for more information.

  • Performing a literature search to obtain current guidelines and to validate and initiate evidence-based practice.

  • Forming multidisciplinary committees to assess and plan for appropriate end-of-life care and education. These committees should include upper management, physicians, pastoral care, nurses, and anyone else interested in this process. Make sure to include people with differing opinions on the subject of end-of-life care so that all sides are incorporated into the final product.

  • Seeking support from physician champions, such as oncologists, who routinely address end-of-life issues.

  • Involving critical care nurses, physicians, intensivists, pulmonologists, and surgeons in discussions about end-of-life care and invite them to join committees.

  • Allowing flexible work patterns and assignments for staff members who may become emotionally drained and need to change assignments.

  • Having supportive services in place to help nurses maintain emotional reserves and to give them an opportunity to vent their frustrations.

  • Identifying crisis intervention teams that may be available if needed for nurses and families.

  • Integrating pastoral care and psychological services to any committees that are formed.

  • Writing and implementing policies, procedures, or protocols for withdrawing life-sustaining treatment according to current national guidelines.

Campbell (2002) further suggests changing current hospital culture; increasing hospital and staff accountability for making end-of-life improvements; increasing public knowledge by having pamphlets, booklets, or other information available; and having early and frequent conversations with families regarding patient prognosis. Campbell also recommends providing ongoing education of ICU staff, as well as unifying care delivery through a systemic analysis of unit barriers, assets, policies, and standards. Rubenfeld and Curtis (2002) recommend making counselors available to families, improving communication and negotiation skills, as well as further evaluating and defining what constitutes a good or bad death. A "bad" death could be one such as the case above where the patient remained tachypneic, diaphoretic, and in obvious discomfort. In addition, the family was in distress over the patient's demise, as well as the accusatory nature of the medical and nursing staff. A "good" death could be one where patient comfort and family support is of paramount importance. All efforts are focused on the patient and his or her physical, psychological, and spiritual needs. Rubenfeld and Curtis also reinforce the idea that patients with a poor prognosis should generate a brief meeting between the family and medical providers, and then be further discussed at multidisciplinary morbidity and mortality conferences. Ethics committees, palliative care teams, spiritual leaders, cultural considerations, and ethnic practices should all be taken into consideration during patient conferences.


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