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:

A Nurse’s Guide to The Art Of Rescue

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Horrified, I watched helplessly on the esplanade as a fuzzy, yellow gosling struggled to right itself from his back in the high water of Oregon’s Willamette River. Four feet away, his mother placidly treaded water, making no attempt to help.

The Willamette River runs swift and cold, with a notorious undertow. Impulsively, I considered jumping in to save the gosling, but the imaginary headline on the evening news played inside my head:

Crazy Nurse Drowns in Failed Attempt to Rescue Gosling. Pictures at Eleven.

Luckily, the gosling righted itself and swam away with its mom and siblings.

I feel a similar sense of helplessness caring for the occasional patient (and sometimes a family), drowning in profound grief expressed as anger.

They present at each appointment with unending lists of complaints. They antagonize their families, find fault with every caregiver, and disparage the home cooked meals generously provided by neighbors. They complain until you contact the oncologist on their behalf, only to find this patient refuses the prescription you are requesting every time his doctor offers it.

Your co-workers snigger when you tell them; they’ve made the same phone call for this patient. You believe your patient is stuck in the grief process at anger, expressing it by making everyone around him crazy. These patients are not violent, nor verbally abusive to nurses. The problem is the amount of energy they require, without solution or resolution. Eventually this may cause nurses to emotionally shun them, like the goose watching her gosling drown.

How can you help these patients without drowning along with them?

  • Enlist the help of nurse navigators, social services, and spiritual care. Some patients will refuse or sabotage this help, but ensure that it’s offered. These experts have experience dealing with these situations. Enlist their help.
  • Resist triangulating yourself between the patient and family, or patient and oncologist. Encourage the patient to interact with caregivers directly by scheduling her own appointments, rides, and prescription refills.
  • Using input from the nurse navigators, social services and spiritual care, create a care plan for this patient. Through consensus, gain buy-in from staff caring for him or her. Some patients benefit from consistent staff assignment — however, beware of establishing “favorite nurses.”
  • A characteristic of dysfunctional grief/anger is playing people (especially nurses) against each other. Ensure the care plan is ethically sustainable for the nursing unit. Other patients know when another receives “special” treatment. Keep things fair.

I think about the goose watching her gosling struggle helplessly, accepting that he may drown. It’s difficult to reconcile this image with the role of a nurse. Not every patient will die a good death, but with a little help, some, like the gosling, may right themselves.

What suggestions do you have for nurses with patients stuck in the grief process?

 

Daylight Savings Time: For What?

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Full Moon Over the Willamette River photo: JParadisi

     Am I the only person who thinks that the little clock on coffee makers should change time via satellite, like cellphones and computers do?

     Tonight, the full moon hangs in the sky like a silvery lozenge, over the Willamette River.  The problem is, it’s only six o’clock in the evening. The early darkness cues my body for sleep. Or to sit in front of the TV and eat. There’s brownie mix in the pantry…

     I am not ready for winter. Why do I need to save time, as if it will be there waiting for me later?