In a DNR situation, respect the patient’s wishes, comfort the family

How we deal with patients who cling to life support is an important issue that’s impact is often overlooked by nursing staff.  Sure, as part of the admit procedure, we will ask the patient or family if they have a living will or DNR on file with the hospital. But mostly, it’s just so we can mark the box one way or the other and move on to the rest of the paperwork that must be completed on each admit.  Many patients eventually get to a point in which full life support is not only futile, but it is just cruel and inhumane.

Stories - Sign Theme Do Not ResuscitateSome physicians are better than others at talking with the family about expected outcomes and chances of living through the experience.  This is one area in which nurses can have the greatest impact, as we get to spend a lot more time with both the patient and the family.  Physicians will nearly always say things like, “We’ll just have to see how things go,” and “There is always a chance that things will improve.”

Having worked several years in the ICU and even longer in the ED, I have come to realize that there are good ways to die and there are bad ways to die.  I want to leave this world in a good way.  Good ways include sudden, massive trauma, dying in my sleep at home, and having a massive CVA or MI in which I’m instantly unconscious and never wake up.  Bad ways to die include being in an ICU as a full code patient, having been ‘successfully’ coded one or more times, but being a cardiac cripple with residual brain damage, or living in an understaffed nursing home for decades, unable to swallow well, ending up with repeated episodes of pneumonia and URI’s.

I used to hate death.
I can keep people alive.
Some wouldn’t want this.
– A haiku from post author Jason Hautala’s book Haiku STAT!: A Poetic Look at the Harsh Realities of Emergency Medicine

When patients die, we, as nurses, can comfort the family by telling them that there are good ways and bad ways to die, and their loved one went in a good way (no matter what the actual case may be).  However, it is even more important for us to take the family aside, share with them the expected outcome, and ask them if what we are doing is really what the patient would want.  Most family members just know they don’t want to lose a loved one, and it is our duty as nurses to refocus the attention back on the patient. We need to make sure the family is acting in the patient’s best interest, even when that means turning off life support and taking care of the comfort measures more than the life sustaining measures.

As nurses we will want to help the family through this decision making process with caring and compassion, but we need to remember that ultimately, we are there for the patient, and sometimes the best thing for the patient is to die with dignity and comfort.

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