DNR Code Status Explained Clearly

By Adem Lewis / in , , , , , , , , , , , , , , , , , , , , , , , , , , , , , /

but welcome to another MedCram lecture
today we’re gonna talk about something a little different in terms of treatment
we could actually talk about DNR full code palliative care just a quick primer
on those sorts of things especially in terms of what we do in the intensive
care unit but also what we do on the floor so I think this is kind of a
confusing topic for some people who are not used to it
DNR stands for do not resuscitate and of course the do and the not are pretty
clear but the resuscitate can sometimes be a little confusing so when someone
says somebody is DNR that means they don’t want to be resuscitated but what
does that exactly mean and I have they fully given consent about what it is
that they want to have done well the opposite of DNR is a term that we
sometimes call full code and that comes from the fact that when somebody in
their heart stops or they stop breathing they have something called a code blue
and it’s during that code blue that you can do all sorts of things and that
would be a full code what I like to do is kind of divide it up into three
different possibilities of things that could happen and really what we ought to
be doing to patients is is not saying to them when they come in if something like
this happens do you want us to do everything because who doesn’t want to
have everything done what we should be doing is we should be telling them
exactly what it is that we’re going to be doing and what are the side effects
of these things so patients and families get a full informed consent so the first
thing is probably the most what we call heroic or the most invasive and that is
basically cardio pulmonary resuscitation this is where we pound on someone’s
chest and we do chest compressions and you know usually you’ve got to go an
inch and a half down to two inches of depth to get really good chest
compressions so that you can actually pump the heart and get the blood flowing
and that can cause rib fractures so CPR and that goes along with all the things
that you learn is something called advanced cardiac life support or ACLs
and then also which goes along with that is shock
so and I’m not talking about septic shock I’m talking about all actual
electric shock so all of these things kind of go together because if you’re
undergoing CPR there’s a chance that you could go into a shockable rhythm so you
could get shock and then you’d be giving things like epinephrine one milligram or
you’d be giving amiodarone or something that goes along with ACLs and these are
medications and so these things are typically done together
unfortunately CPR ACLs shock in terms of in hospital cardiac arrests are usually
not very effective but they do have a high incidence of for instance breaking
ribs and so patients need to be aware of that so if someone’s coming in to the
hospital from a trauma and otherwise healthy CPR ACLS shock may otherwise get
them back on the road but if someone’s being admitted to the hospital after
many bouts of pneumonia because of lung cancer and they’ve just you know had it
they don’t want to have any more of this intervention this may be something that
they don’t want to have done to them so making sure that they’re aware of that
is important so that’s CPR ACLs in shock and they
kind of go together the other thing that can happen is something called
intubation so intubation is where we put a tube
down someone’s throat obviously into the trachea they can’t talk and they usually
have to be sedated and we do this either because they can’t breathe for
themselves or their neurological status is bad enough so that they can’t protect
their airway putting someone on an ET tube endotracheal tube is not a benign
process especially when someone is unstable we have to sedate them usually
with medications and sedatives and sometimes also paralyze them so we can
intubate correctly there’s a risk of aspiration there’s a risk of trauma
there’s a risk of hypotension of coding all of these things could happen if we
were to do intubation and there’s a risk that the ET tube could go down too far
and you could have a right mainstem bronchus intubation etc etc so those are
all complications but sometimes you need to do intubation and that’s usually
pretty effective at protecting that airway the last one is probably the
least invasive and that’s Bayes oppressors
and please look at our video on bayes oppressors for more information about
that but these are basically medications that we would give in septic shock to
increase the blood pressure to make sure that the map or the mean arterial
pressure is greater than 65 millimeters of mercury medications like Levophed
medications like epinephrine vasopressin neos a nephron these are the sorts of
things and typically we like to put these through central lines or if
they’re going through peripheral lines we we want to make sure that they’re not
too concentrated and they’re going through the right peripherals because if
they infiltrate they can cause some serious tissue damage so what’s the risk
of vasopressors the risk of a suppressors is is that if you give too
much it could cut off circulation to the extremities and that can cause necrosis
they can cause arrhythmias you need to put central lines in for those and so
what I like to do when a patient comes in is instead of asking them do you want
us to do everything because the question is is who wouldn’t want you to do
everything that you could possibly do the reason why we’re asking it is
because there’s significant side effects to these very invasive procedures and we
want to make sure that it’s in line with the values that the patient wants to
have so be very specific I would ask the patient if if your heart were to stop
would you want us to run in there and do chest compressions and to pump on your
chest an inch to two inches to get your heart going and pumping knowing that we
could be breaking ribs and we might have to put a chest tube in after because of
a pneumothorax do you want us to be giving you medications do you want us to
be shocking you and then let them know what the side effects of those things
are and obviously let them know that the only benefit would be to get them back
where they were before their heart stopped would you want us to put a tube
down into your lungs and put you on life support and on a ventilator where you
can’t talk and you have to be sedated and this would be of course to protect
your airway or to continue your breathing would you want us to put you
on medications that might require a special type of IV access so that we
could keep your blood pressure up some patients don’t want to have these things
and if they don’t want to have any of these things then the term that we
typically use is DNR D&I and this DNR dni status would go on
their chart and the reason why is because you don’t have time to call the
family if the patient codes on the monitor so you have to make sure that
that’s the case if they want any of these things to be done so if they’re
actually interested in let’s saying vasopressors then the term would be a
modified code and you’d make sure that that was specified on the chart so that
they would know to give vasopressors in that situation but perhaps maybe not cpr
or perhaps not ACLs so a discussion that’s good to have with patients when
they come into the intensive care unit is what I like to call the pillar talk
and the pillar talk is a good representation I believe of what happens
in the intensive care unit so the first thing that I tell them is that the
patient’s life is like a roof it’s a ceiling and it’s being held up by
pillars okay and these pillars are the body’s organ systems so for instance one
organ system is the heart another organ system might be the lungs another organ
system might be the kidneys and another organ system might be the immune system
okay but these pillars are all working in conjunction with each other and they
all are being used to keep the patient’s life now what happens in the intensive
care unit is usually patients are in the intensive care unit because they have
problems with one or two of these organ systems so in other words the heart
system may fall down or the lung system may fall down and so as these pillars
start to fall down more and more weight gets put on the remaining pillars so
obviously if the more pillars fall down that’s going to put more stress on the
remaining pillars and the whole roof and the whole system could come down and
that’s obviously equating to death and so what we do in this situation is if we
see the heart pillar fall we identify that and we hold up that
system while that heart pillar has fallen down in this case the way we
would do that would be through vasopressors so if the cardiovascular
system is not working we hold up the roof in that area where the heart pillar
used to be if the lung pillar has fallen down we
hold up that part of the roof with the ventilator if the kidney pillar has
fallen down we hold up that part of the roof with hemodialysis and so what we’re
doing is these patients who are in the intensive care unit are on life support
we’re holding up those portions of the ceiling the roof if you will while the
patient’s pillars have fallen down and then what we do is we wait to see if
those pillars through supportive care and regeneration of the body which
obviously happens at a younger age better than it does at an older age but
if we start to see these pillars come back up again in a way that we can then
pull off the support for instance in that situation stop dialysis if these
pillars start to come up in a way that we can pull off support for instance we
in the patient off the ventilator or in the example of the heart pillar we can
get them off of vasopressors then we can pull off support and the patient gets
better the key here though is not how we do the support of the patient obviously
we want to be as careful as possible in supporting the patient but it’s really
up to the patient’s ability and the vitality of that patient to bring those
pillars back up okay and so what we typically see is three different
possibilities and the intensive care unit we see the patients whose pillars
are down but they come up very quickly and we’re able to get them off life
support and out of the intensive care unit and then we see patients who the
pillars are falling down and despite the fact that we’re holding up the pillars
additional pillars continue to fall until finally we’re just not able to
hold up the roof and the whole the whole roof comes down despite all of our
support and the patient passes away in the intensive care unit and then the
third type is that we’re holding up all of these pillars here we’re giving
support through the ventilator through Bay’s repressors through dialysis
through antibiotics for the immune system etc etc and despite that we’re
kind of stuck in a holding pattern where the
pillars are not coming back up and we’re still holding the roof and then we get
into discussions with the family about how long they would want their loved one
to be on these life support and you know sometimes patients will say to their
loved ones look if if I’m sick and I’m going into the hospital you know go
ahead and do everything you can for at least you know a few days and if it
looks like nothing’s working and I’m stuck on this life-support then don’t
leave me on life support just go ahead and take those off if the patient’s
Pilar’s come up really quickly and everything’s going well we just we wean
off the ventilator we wean off the vasopressors we can take the patient off
dialysis we can end the antibiotics because the immune system has now
replenished itself and that’s great the patient gets stepped down to the regular
floor when they’re able to do their activities of daily living they living
they can go home from the hospital but in the situation where the patient is
continuing to get worse and worse and worse and other pillars are falling
despite the fact that we’re holding up and supporting the patient’s life that’s
when I have a discussion with the family and I bring up that discussion that we
talked about before with CPR because all of these things that we do here in the
intensive care unit when we’re holding up the ceiling with vasopressors with
antibiotics with the hemodialysis with the ventilator these are very effective
things very effective at holding up the ceiling if everything’s falling down and
the last thing that we have left is CPR CPR is not very effective very low
survivability with in-house CPR in other words if the heart stops it’s stopping
for a very good reason typically and so when I approach the family with this
information usually what they will say is look if you’ve done everything you
can through these very effective measures here trying to keep the roof up
through dialysis through vasopressors through antibiotics things that are very
effective and they are not able to work and turn the patient around and we get
to the point where the heart stops then just let the heart stop and don’t do the
CPR and I think once you explain to them the risks and benefits then they’re more
apt to not do CPR now some wanted do CPR and we’re happy to do that but
that’s a decision that has to be made always before the time comes for CPR and
the reason is is because when the time for CPR comes there is no time to call
family that’s the decision that has to be made before the time comes so I hope
this discussion was helpful in the next video we’re going to talk about what
kind of a discussion that we have with family in the intensive care unit where
we’re stuck in that situation where the patient’s not getting any worse the
patient’s not getting any better and the patient’s been on life support for days
perhaps even weeks and they don’t want to have that anymore because it’s not
consistent with the patient’s values so let’s talk about that in the next video
thanks for joining us

9 thoughts on “DNR Code Status Explained Clearly

  1. Great job explaining at a level many can understand. From a nurse perspective, it helps to be able to break down what we understand in a way the family/patient can relate to. Thank You!

  2. View the complete course 𝘿𝙉𝙍 𝘾𝙤𝙙𝙚 𝙎𝙩𝙖𝙩𝙪𝙨 free at https://www.medcram.com/courses/DNR-code

  3. Great work! My only suggestion on the content is that I would avoid using the term “modified code” as it mixes the intended meaning of code as in code status (dnr vs full code) with care preference such as the use of vasopressor. If a patient does not want vasopressor and you would want to document it, instead of using the term modified code, I would simply write “no vasopressor” to clarify one’s care preference. So much confusion arises from mixing code status with care preference and as a palliative care physician, I try to separate them in my daily practice as frequently as possible so that other providers can learn as well. Thanks

  4. Ooh I like your Pillars metaphor on 7:52! I will use that when talking to my patients about it. Thank you so much.

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