A DNR or a do not intubate (DNI) order, is an advanced directive intended for critically ill patients who wish to decline emergency interventions like CPR, ACLRS, or life-sustaining equipment. In this article, we’ll take a closer look at what a DNR or DNI means for both you and your patients when they are most often requested, and how to communicate effectively with your patients about their options.
Resuscitation is the act of using CPR or other medical techniques to revive a patient in critical or near-death condition. The act of resuscitation can involve several different things, depending on the circumstance at hand. Though we often associate resuscitation with using chest compressions to restart the heart, it could also mean using intubation to help a patient breathe.
Alternatively, resuscitation could also mean the introduction of fast-acting tools, medications or fluids to help stabilize the body — this could include donated blood, an IV drip. In some cases, resuscitation might mean the use of a defibrillator, which sends an electric shock to a patient’s heart if their heartbeat is out of sync.
A patient may require intubation, regardless of whether they need cardiac resuscitation. As previously mentioned, intubation is meant to help a patient breathe. During intubation, soft plastic tubes are placed down the patient’s trachea. This tubing connects to an external ventilation machine that mechanically pumps air into the patient’s lungs. In an emergency, health workers can attach this tubing to an apparatus to allow them to pump air manually. Medical professionals also use intubation to administer some medications more easily.
If medical staff deem intubation necessary, they will likely put their patient in a medically induced coma, though they may introduce tubing while the patient is awake during a time-sensitive emergency. When the patient becomes stronger and is able to breathe without help, the tube is removed in a process called extubation.
When Are DNR and DNI Used?
DNI and DNR orders are seldom heard of during cases in which a patient becomes critically ill in a short period of time, or if someone is badly injured in an accident. In cases like these, first-responders and emergency healthcare workers are expected to do everything they can to keep their patients alive.
DNR/DNI orders are more often seen in cases of long-term or intensive care. In these situations, patients and their families must be able to fully comprehend their doctor’s diagnoses and make level-headed decisions about their health in the event that they run into future complications. If this is the case, a patient holds the right to deny resuscitation, intubation, or both in the future.
DNR/DNI orders cannot be requested in the middle of an emergency, during which either resuscitation or intubation are needed. There are serious legal ramifications to face if you do not attempt resuscitation if a patient does not have an officially documented order. After signing it themselves, a patient’s DNR order must be signed by their doctor, physician’s assistant, or nurse practitioner. The document is typically a one-page record, complete with checkboxes that allow a patient to deny resuscitation and/or intubation.
Patients cannot create their own DNR/DNI orders. If they have been diagnosed with a terminal condition or a negative prognosis, the medical professional overseeing their care must consult with them to help navigate their options in the event of a future life-threatening occurrence.
In most hospitals and healthcare facilities in the US, DNR/DNI consultations are not mandatory — as a healthcare worker, you are not required to bring up this option unless your workplace has a protocol in place that says otherwise. However, you should still be prepared to have a DNR/DNI consultation if you are prompted by a patient.
Communicating With Patients About DNR/DNI
Not sure how to go about the best way to discuss a DNR request with your patient? Here are a few steps you can take to ensure a comfortable and reassuring conversation.
Initiate an Understanding Discussion
The key to helping any patient make tough decisions is to establish a positive relationship from the beginning of your time with them. Being a pillar of support from the moment they come under your care will encourage your patient and their family members to trust you and your professional opinions. You can establish trust by being compassionate and showing empathy to both the patient and their surrogate decision-maker. If treatment becomes ineffective and your patient becomes terminally ill, it is your job to listen and guide your patient through their difficult time.
Be Clear About Your Prognosis
Death is an uncomfortable subject but as a healthcare worker, it’s important that you approach it with empathy and directness. Though it can be hard not to be optimistic, make sure your patients are fully aware of their condition and that there is no chance that they will misunderstand the information you’re providing them. Deliver each prognosis with simple, comprehensive wording. The harder the news, the simpler the phrasing.
Identify Your Patient’s Goals
If your patient decides to sign a DNR/DNI order, your next step should be to help them recognize their goals. For many patients in critical condition, these goals tend to be:
- Leaving the hospital or healthcare facility
- Spending as much time with family and friends as possible
- Minimizing pain
- Maintaining mobility and functionality
Speak to your patient about their goals and try to find ways in which you as a healthcare worker can help them achieve them.
DNR/DNI orders can be nerve-racking if you don’t have experience in dealing with them. But by staying level-headed and keeping communications with your patient open and honest, you’ll be able to help maximize their quality of life in the time that they have.
Keep in mind that DNR/DNI orders are a rare occurrence — you should always keep up to date on the latest CPR, ACLRS, PALS, and BLS procedures. Do you need to receive or renew your certifications? ProMed has you covered. Check out our list of quick and cost-effective certifications today!
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