Mr. P, 46, was admitted to the ICU with severe pulmonary hypertension and right heart failure. Transferred from a smaller community hospital 150 miles away, Mr. P needed specialized treatment of his severe right heart failure and pulmonary hypertension due to chronic pulmonary emboli. Mr. P's wife came with him.
After a right heart catheterization, Mr. P's physician determined that his case was nonoperable. He was maintained with medical treatment to reduce his symptoms. The pulmonary team discussed the outcome and treatment plan with Mr. and Mrs. P, who decided on a "do not resuscitate" (DNR) status. Mr. P remained in the ICU for several days, during which time the staff questioned whether the patient should remain in the ICU if he was a no-code patient.
Do not resuscitate
Does a "no-code" or DNR patient ever belong in the ICU? The answer to that question is complex. Initially, the ICU may not appear to be the appropriate choice; however, the needs of the patient and family as a unit must be considered. The best solution for consideration is one that accounts for the patient's and family's needs and goals.
The Code of Ethics for Nurses with Interpretive Statements clearly states, "The nurse respects the worth, dignity, and rights of all human beings irrespective of the nature of the health problem. This extends to all who require nursing services for all health conditions, including the alleviation of suffering and the provision of supportive care to those who are dying."1
Experts studied the effect of DNR orders on nursing care of critically ill patients. Findings suggest DNR orders may be misinterpreted to mean something other than no cardiopulmonary resuscitation. Several factors were attributed to the findings, including a misinterpretation of the policy. Recommendations include clarifying DNR orders by differentiating specific interventions and holding ongoing discussions with the family and healthcare team. Other findings support the intensity of psychosocial interventions required by patients and families. Participants reported the psychosocial interventions were as time consuming as invasive physiologic treatments in many cases.2
Patients in the ICU with DNR orders may need aggressive symptom management or medication administration, requiring the expertise of the critical care nurse. Patients or families may need extensive explanations and psychosocial support during an extremely stressful time.
Mr. P and his wife needed to talk about options with the healthcare team. Symptom control, as a goal, was of paramount importance to Mr. and Mrs. P. DNR doesn't mean "do not treat," rather, it means the nurse must not resuscitate the patient if an arrest occurs. Many people have DNR orders, but want full treatment up to arrest.
Occasionally, the DNR decision is perceived as a "failure" by the team. Yet the patient's death and how it's handled by the healthcare team can turn a time of tragedy into a time of resolution and healing. Care of the whole individual and family is where critical care nurses touch hearts and save lives.
During the course of unit rounds, staff were encouraged to reflect on the care of Mr. P. He died peacefully two nights later after saying good night to his wife.
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