Download What does DNR/DNI really mean?

CLI N IC AL QU ER I ES
What does DNR/DNI
really mean?
Recently, an older adult with
metastatic bladder cancer was
admitted to our unit with donot-resuscitate (DNR)/do-notintubate (DNI) orders. She also
has an implantable cardioverter
defibrillator (ICD) because of
a history of sustained ventricular tachycardia. Should the ICD
be deactivated?—A.H., MINN.
Christine M. Barlow, RN, replies:
A DNR order, which must be written by a healthcare provider, documents the patient’s wish to avoid
CPR in the event that he or she
is unresponsive and apneic, with
or without pulses. The order addresses resuscitation interventions,
which may include rescue breathing, chest compressions, defibrillation, and advanced cardiovascular
life support interventions. DNI
directs caregivers not to intubate
the patient and initiate mechanical
ventilation in the event of acute
respiratory distress or apnea.
A DNR/DNI order may be chosen
by patients who are near the end of
life or who have a serious condition
that won’t improve. It limits only the
provider’s actions to resuscitate a
patient who’s pulseless or not breathing; it doesn’t restrict other clinically
indicated care.1 A patient can revoke
a DNR at any time.
Whether an ICD should be deactivated for patients who have a DNR/
DNI status depends on each patient’s clinical status and wishes.
As the health status of a patient
with a terminal illness changes, he
or she may or may not wish to have
the ICD deactivated. In the case of
your patient, deactivation of cardiovascular implantable electronic
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devices, including an ICD, should
have been part of the discussion
about DNR status. ICD deactivation
may have different connotations
to the patient and her family than
DNR status because they may see
it as removing care rather than
refusing further treatment.2
As a patient nears the end of life,
however, the ICD’s response to a
dysrhythmia may become burdensome and futile. Kirk cites a case
study in which a patient with terminal leukemia in palliative care
had an ICD due to preexisting
heart disease. Though the caregivers were aware of the ICD, no one
discussed deactivation with the
patient and the device discharged
six times before the patient died.2
Ongoing communication between
patients and their healthcare provider
helps protect them from unwanted
treatments as they near the end
of life.
For more information, see the
HRS Expert Consensus Statement
referenced below.3 ■
REFERENCES
1. Dugdale DC III. Do not resuscitate orders. Medline Plus. 2014. http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000473.htm.
2. Kirk TW. Deactivation of automatic implantable
cardioverter-defibrillators in hospice and home
care patients at the end of life. Home Healthc Nurse.
2008;26(7):431-437.
3. Lampert R, Hayes DL, Annas GJ, et al. HRS expert
consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in
patients nearing end of life or requesting withdrawal
of therapy. Heart Rhythm. 2010;7(7):1008-1026.
Christine M. Barlow is an RN at Rochester General
Hospital in Rochester, N.Y.
The author has disclosed that she has no financial
relationships related to this article.
DOI-10.1097/01.NURSE.0000451538.47964.7b
August l Nursing2014 l 65
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.