DNR Does Not Mean Do Not Treat

Nurses and the meaning of DNR.

I recall a patient I had as a very new nurse who was designated as do not resuscitate, or “DNR.” The patient had suffered an intracranial bleed and because of his advanced age and untreatable cancer, his family had agreed that no CPR should be used. I remember the nursing supervisor asking me why the patient didn’t have a footboard and foam heel protectors on (that’s what we did back then); my answer was that he was a DNR patient. She basically handed me my head and said that his DNR status had nothing to do with good nursing care.

I never forgot that incident, and when I spoke with the authors of a mixed methods study with direct care nurses on three different units that found that “varying interpretations of DNR orders among nurses were common,” I immediately said yes. Their article is the original research article in AJN‘s January issue, “Nursing Perspectives on Caring for Patients with Do-Not-Resuscitate Orders.”

Families and providers may understand DNR differently.

And it’s not just nurses who may have different ideas and think differently about what should or shouldn’t be done for these patients who hover between life and death—other health care providers and families need to be clear on what that […]

2021-01-27T11:35:45-05:00January 27th, 2021|Nursing, nursing research|1 Comment
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Control: Ninety, and Still Haunted by a Husband’s Dying Promise

I will forever be haunted by the passing of Mrs. Haley. On the final days of her life, I was deemed her best, last support, because I knew something about the dangers of control. Or so I thought.

Work that changes you.

‘I will know, and you will pay’

One aspect of having a diverse occupational history within the mental health field is that you take something with you from every experience. However, there was one job that I wanted to walk away from clean, having taken nothing. Prior to becoming a nurse, I worked as an advocate for a domestic violence shelter. The position involved community education, outreach advocacy, supportive therapy, and violence prevention school programs. Those five years of my life were a relentless and eye-opening study of the dangers of control.

Domestic abuse or intimate partner violence is all about control, about an unhealthy balance of power in an intimate relationship. Advocates in the shelter provide a voice for the victims who suffer from domestic violence. Anyone can be vulnerable, regardless of gender or identification. According to the CDC, one in four women have experienced intimate partner violence (and one in nine men). Intimate partner violence remains a pervasive undercurrent in our culture, one still supported in […]

2019-04-05T09:50:54-04:00April 5th, 2019|Nursing|1 Comment
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Who Is Doing Advance Care Planning in Nursing Homes?

When I was an ED nurse in a city hospital years ago, we often received patient transfers from area nursing homes. Usually these patients were very elderly, appeared cachectic, and were largely unresponsive (as I recall, many were post-stroke or had dementia). Diagnoses were usually very similar: dehydration, hypotension, UTI, pneumonia; many had contractures. The usual care was rehydration with IV fluids, an NG tube, antibiotics, and often a Foley catheter. Sometimes they were septic and then they were intubated, placed on ventilators, and sent to the ICU, where just about everyone died after a short stay.

What’s the point of this care?

I often wondered, as did many of my colleagues, what was the point of this. It seemed futile, and injurious to the patient. Sometimes, if we could reach family members before nasogastric or endotracheal tubes were placed, we were able to secure an order to dispense with all but comfort measures. Otherwise, all measures were initiated and then things became complicated—legal issues arose about discontinuing futile care and families often couldn’t bring themselves to discontinue life support measures.

Today, a greater focus on advance care planning.

Advance care planning (ACP) was hit or miss in those days—mostly miss—and our patients suffered because of this. It’s only recently that emphasis has been placed on making […]

2018-12-10T11:07:41-05:00December 10th, 2018|Nursing|0 Comments
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How a Patient’s Family Heals a Nurse in this Era of Medicine

“This family’s brave, selfless, and clear-minded approach to their daughter’s last days showed me that it is still possible for me and my colleagues to heal in the ways we want to heal, hurt in the ways we accept we will hurt, and not harm in ways we never, ever intended to harm.”

A painful contradiction of pediatric ICU nursing.

One of the things that feels most unfair about pediatric ICU nursing is that with critically ill children, you don’t get the comfort of being able to look back and say, “At least they lived a long and happy life.” You ache that a baby, a toddler, a school-age child, a teenager was supposed to have their whole life ahead. But instead, much of their short life was marked by illness, prods and pokes, lines and tubes, sedation rather than play, a sterile environment full of strangers at all hours rather than a home full of time with friends and family.

The deep desire in both the parents as well as the health care providers to do anything possible to give them a shot at a future is in and of itself right and good. Yet the decision about how much to push both medicine, and the child as the obligatory recipient, in the fight for a future that is neither guaranteed in quantity nor quality can often be wrought with controversy and ethical distress. Clinicians do not necessarily find peace with their work just because a life was physically saved; sometimes quite […]

2018-08-01T10:47:19-04:00August 1st, 2018|Nursing|0 Comments
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Not Until Cairo: A Flight Nursing Tale

Worsening signs.

The author’s flight path circled the globe

The cabin of the Learjet is dark, the heart monitor a metronome over the drone of the engines and pulse of the mechanical ventilator. I’ve been watching my patient’s cardiac rhythm, with ominous hackles rising on the back of my neck while my partner naps. Over the course of the journey the man’s inherent tachycardia has slowly shifted into a sinus rhythm that might seem like normalization on a paper medical report, but feels wrong. After all, this patient is dying. He is returning to Egypt to die amongst family after last-ditch cancer treatments in America have failed.

“Not on this flight,” I think to myself. “Not until Cairo.”

The plane banks as it descends into the Newfoundland night. The cabin vibrates with turbulence; St. John’s may be the most easterly North American fuel stop, but its position on the Atlantic all but guarantees unpredictable weather. The lights of the town sparkle below as my partner rouses, pops his ears, and stretches.

“Look at his heart rate,” I say, quietly. “Pressure’s okay, though.”

“Yeah,” he says. There’s an unspoken accordance between us. We’ve flown together enough—been trapped in small planes for countless hours, evaluating and collaborating—that we easily […]

2018-06-21T10:11:27-04:00June 21st, 2018|Nursing, nursing stories|4 Comments
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Views expressed on the blog are solely those of the authors or persons quoted. They do not necessarily reflect AJN’s views or those of Wolters Kluwer Health/Lippincott Williams and Wilkins.
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