Thoughts on Cairns, Advanced Directives, and DNR Orders

Cairns are ancient, human-made stacks of rocks indicating a landmark or memorial site.

Cairns by jparadisi

Cairns by jparadisi

Modern-day hikers use cairns as directional markers for those following their trail. Not long ago, I came across a group of cairns while walking along the Willamette River. Most likely, they were merely an artistic expression, but only the person who left them knows for sure.

In a way, Advanced Directives and DNR orders are healthcare cairns, marking directions for end of life journeys. Also like Cairns, without an understanding of the patient’s intent, their meanings become open to interpretation, and subsequently, misinterpretation.

Misinterpreting Advanced Directives and DNR orders is a common occurrence among physicians and nurses.

A series of surveys by QuantiaMD, an online physician learning collaborative, found that nearly half of health professionals misunderstood the components of living wills — 90 percent of those surveyed were physicians.¹

The survey findings provided characteristics of a patient who had a living will, and asked respondents to identify the patient’s code status. Of about 10,000 respondents — 44 percent incorrectly identified the patient as having a DNR, and 16 percent did not know the code status. About 41 percent correctly identified the patient’s status as a full code.¹

The majority of survey respondents wrongly said patients with DNRs should receive significantly less medical care and interventions than designated by such an order. A DNR means that a patient should not be resuscitated if found with no pulse. About 20 percent said they would defibrillate a patient who had a clear DNR order.¹

Much confusion stems from the lack of a national standardization of end of life directives, and their communication to a patient’s healthcare providers. One article describes a hospital using yellow armbands to indicate that a patient has DNR orders.²  Oncology nurses will especially appreciate the problem created for that hospital’s oncology unit, where many patients arrive wearing yellow Livestrong bracelets in support of finding a cure, not as a declaration of DNR status!

Terminology also contributes to confusion. Many physicians and nurses wrongly interpret DNR (Do Not Resuscitate) to mean Do Not Treat. Reviewing a patient’s Advanced Directives, DNR orders, or POLSTs (physician orders for life-sustaining treatment), and making them readily available to a patient’s healthcare team, helps prevent unwanted treatments, while providing comfort care per the patient’s wishes.

In March 2012, The ANA Center for Ethics and Human Rights revised their position statement, “Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions,” defining the responsibilities of nurses following end of life orders.

What are your experiences with end of life orders? What is your institutions’ policy?

References:

You’ve Come a Long Way Baby. Maybe.

Untitled. photo: jparadisi 2011

A friend of mine talks about aspects of one’s life occurring between bookends.  People use the cliché “things come around full circle” to mean the same thing, but I like my friend’s reference to bookends better. Coming full circle suggests ending back where one started, but the bookends metaphor implies a linear journey that includes revisiting one’s past, which is unavoidable if you live long enough. Personally, I prefer the bookends metaphor to the circle one, because I think moving forward is an important attribute of  happiness.

Today was my second shift using the new electronic medical record. Yesterday I practiced order entry, updating the home medication list, and documenting blood transfusions. Today, I focused on medication administration. The way the EMR works in our hospital, patients wear a bar code wristband and the medications are bar coded too. When giving a medication, the nurse deploys a laser scanner the size and shape of a pistol to scan both the patient and medications, verifying that the right patient receives the right medication, an important upgrade in patient safety. Scanning the bar codes exactly right so they register in the EMR is tricky. Most of the time I had to repeat the scan more than once before I got it right. I’m thinking it’s not very different from learning to start IVs: eventually my small motor coördination will develop muscle memory, and I will have a “feel” for getting it right the first time. It just takes practice.

Sometime during the course of the shift, however, I told a coworker that if my scanning ability doesn’t improve, my plans for a career at Whole Foods are doomed. We laughed. Then I remembered something from my nursing school days:

When I entered nursing school there was a nursing glut. Nursing shortages hadn’t occurred since before Salk invented the polio vaccine, and tuberculosis ran rampant. Around the same time, grocery store chains were investing in a new technology using lasers to scan bar codes on grocery items for prices at check out. After attaining my Registered Nurse license, I could look forward to eventually earning the same hourly wage as grocery clerks then. All through nursing school, both instructors and students joked about “scanning cans” for a living, if our careers in nursing didn’t pan out.

My very first nursing job paid an hourly wage of thirteen dollars and some change. Six months after graduation, the first wave of a nursing shortage hit where I lived, and my hourly rate nearly doubled in a single pay raise; a windfall. I never thought about scanning cans again, until today when I aimed a laser scanner at a patient’s wristband and medications, and I realized I have traveled a straight line punctuated by a bookend.