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Journal of Neuroscience Nursing:
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DNR Does Not Mean No Care

Fields, Lorraine

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Author Information

Questions or comments about this article may be directed to Lorraine Fields, MSN CNS, at fieldsl@summa‐health.org. She is a critical care clinical nurse specialist in a level I neurotrauma unit at the Summa Health System, Akron, OH.

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Abstract

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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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.

Nurses must be actively involved in palliative care.

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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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 evidencebased 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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Summary

End‐of‐life care involves a systems approach to change a hospital culture. Hospitals need to liberalize visiting hours, provide educational materials regarding critical illness, and make counselors available to families. Care managers, patient care coordinators, and pastoral care may be used to coordinate further family and spiritual care. Nurses should attend and organize palliative care in‐services and other education offerings and make sure all new employees attend palliative care and hospice classes during their orientation. In addition, nurses need to be proactive with end‐of‐life care and refuse to accept substandard patient care from healthcare workers that are not familiar with end‐of‐life issues. Unfortunately, none of these measures were taken for this patient. However, as a result of communication between the hospital and the patient's daughter, a new palliative care team was formed and is in the process of educating staff. Comfort care involves comfort for the patient and family—and that should be the priority.

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References

Campbell, M. L., (2002). End of life care in the ICU: Current practice and future hopes. Critical Care Nursing Clinics of North America, 14, 197-200.

Gajewska, K., Schroeder, M., De Marre, F., & Vincent, J. (2004). Analysis of terminal events in 109 successive deaths in a Belgian intensive care unit. Intensive Care Medicine, 30, 1224-1227.

Rubenfeld, G., & Curtis, J. (2002). Beyond ethical dilemmas: Improving the quality of end-of-life care in the intensive care unit. Critical Care, 7, 11-12.

Summa Health Systems. (2006). Terminal wean order set. Akron, OH: Author.

Truoug, R., Cist, A., Brackett, S., Burns, J., Curley, M., Danes, M., et al. (2001). Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Critical Care Medicine, 29 (12), 2332-2348.

World Health Organization. (2006). WHO definition of palliative care. Retrieved August 9, 2006, from www.who.int/cancer/palliative/definition/en/.

© 2007 American Association of Neuroscience Nurses

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