DNR form not filled out completely

Hey guys I have a really important question to ask. I just graduated this may and currently working in a nursing home. I have one resident whom just coded today.

Upon arriving on shift, my unit manager told me that the patient is still full-code and not DNR. The DNR out-of-hospital order form is still haven't been filled out by the doctor, hospice, and the nephew (the responsible party of the resident).

While doing rounds and preparing to put on wound care dressing on this resident I saw that she was having trouble breathing and using her accessory muscles. I immediately took her vitals and Sp02. The Vitals were BP= 89/53 Pulse= 116 Respirations= 27 and Temp 97.4. Her Sp02 was 85% and steadily declining. I called respiratory right away to give her some oxygen which her sP02 increased to 79%.


I had to call 911 to come pick her up.

The question is I saw in her chart that the doctor did put down DNR and sign it in one of those receipt attachment form. However, it wasn't an official out-of-hospital DNR order form. I called the director of nursing and she told me the patient is DNR. I rush to the patient's chart and pull out that particular DNR form to show to the EMS people. They told me that form isn't valid because its one of those tear off form. It has to be an official out-of-hospital DNR form for her to be DNR. They took her to the hospital.

I'm really worried because 1) there was a DNR order from the doctor. 2) The doctor nor the nephew has officially sign on the out-of-hospital DNR order form.

I'm stuck between which one to follow. I'm really stress out right now. I had to stay back 4 hours to do paperwork and check if everything was correct. I did saw in the chart that her last advance directive flowsheet was done on 10/19/11 which was 2 years ago. That one still listed her as full-code and not DNR.
DNR does not stand for Do not treat. It sounds like she did not code at your facility so it is out of your hands. I'm my state, if a person codes in the ambulance they do CPR regardless of code status. I'd say as long as you sent the necessary paperwork along then it is the hospital that would be up to them to decide how to proceed. It is always good to clarify code status if possible. We had a lady that started a general decline that carried into a weekend and was a full code. Her daughter decided that she wanted to make her a DNR. We called the on call and expressed her wishes. He was able to talk to the POA and give us a TVO and that was considered sufficient at our facility.

Quote from CaringGerinurse525DNR does not stand for Do not treat. It sounds like she did not code at your facility so it is out of your hands.

A DNR is not a do not treat. You administered oxygen.....perfectly acceptable. You called 911...again Ok. Just because someone is a DNT doesn't mean they shouldn't get lasix to help them breathe or antibiotics to help a urinary tract infection.A DNR means you won't do CPR or perform life saving measures...like intubation, defibrillation, and pressors.Without a signed DNR there is no DNR. CaringGerinurse525 is incorrect about EMS having to have to do CPR. I believe that all states have out of hospital DNR status which when signed allows EMS to withhold resuscitative efforts.In my state it is called Comfort Care.... MOLST and Comfort Care DNR Verification In PA it is called a out of hospital DNR order.....DNR Order - Pennsylvania TX out of hospital do not resuscitate order...http://codes.lp.findlaw.com/txstatutes/HS/2/H/166/CDo Not Resuscitate Orders and Comfort Care OhioAre a few examples....But these need to be filled out and signed for them to be valid.

The big issue in calling 911 would be if there was a DNH (do not hospitalize order ) My father was made a DNR, DNI, DNH. & on hospice. One nurse panicked and sent him out for possible UTI then called us & hospice. It was a big unnecessary mess especially since hospice was awesome and had wonderful care plans & med orders in place. If she had fallen with a possible hip fracture & DNR you would still call 911 for an ER evaluation and at minimum pain management if surgery wasn't an option. EMS in some states not initiate CPR after consult with ED medical control if there isn't legislation permitting EMS to accept facility specific DNR forms at face value.

Quote from Esme12A DNR is not a do not treat. You administered oxygen.....perfectly acceptable. You called 911...again Ok. Just because someone is a DNT doesn't mean they shouldn't get lasix to help them breathe or antibiotics to help a urinary tract infection. A DNR means you won't do CPR or perform life saving measures...like intubation, defibrillation, and pressors. Without a signed DNR there is no DNR. CaringGerinurse525 is incorrect about EMS having to have to do CPR. I believe that all states have out of hospital DNR status which when signed allows EMS to withhold resuscitative efforts. In my state it is called Comfort Care.... MOLST and Comfort Care DNR Verification In PA it is called a out of hospital DNR order.....DNR Order - Pennsylvania TX out of hospital do not resuscitate order...http://codes.lp.findlaw.com/txstatutes/HS/2/H/166/C Do Not Resuscitate Orders and Comfort Care Ohio Are a few examples....But these need to be filled out and signed for them to be valid.

Quote from CaringGerinurse525 I may be wrong, Esme but I know at my facility we are told that out DNR forms are not upheld in the ambulance. We have a gentleman on hospice right now and his family had to request a specific form to sign so that there was no chance they would resuscitate him. This was news to me because I assumed if the hospital would honor the DNR then so would EMS. I am a fairly new nurse so when the situation arose I spoke with the RN's, DON and social worker. They all told me it was standard protocol that the Ems are held to a different standard. I will have to investigate this further. Thanks for the heads up.

Quote from JustBeachyNurse For what reason would you be calling EMS anyway? I know many hospice agencies encourage patients/families to sign DNH (do not hospitalize) orders depending on diagnosis/prognosis. Check also with the hospice case manager they often have suggestions for interventions and when it is necessary to send out for further eval. In my father's case, at the end sending him to evaluate/treat pneumonia or a UTI would be of little benefit and likely cause more harm (such as more c. diff. , MRSE, VRE, or other MDR superinfection). Hospice had comfort orders for Tylenol, morphine, atropine and other palliative measures. So he was made a DNR/DNI/DNH.

Quote from CaringGerinurse525I may be wrong, Esme but I know at my facility we are told that out DNR forms are not upheld in the ambulance. We have a gentleman on hospice right now and his family had to request a specific form to sign so that there was no chance they would resuscitate him. This was news to me because I assumed if the hospital would honor the DNR then so would EMS. I am a fairly new nurse so when the situation arose I spoke with the RN's, DON and social worker. They all told me it was standard protocol that the Ems are held to a different standard. I will have to investigate this further. Thanks for the heads up.

I live in PA. I read the link you posted pertaining to PA. I work in LTC so I do not have as much experience with EMS as some nurses do. It is interesting to learn that a separate form is required. I will be sure to pass this information on to the other nurses I work with that may also not be aware. Thank you!

That was a lucky....I posted where I have worked before...LOL...you are very welcome

Quote from CaringGerinurse525 Our DNR's are not always do not hospitalize. I was just using the hospice patient as an example. We would send a hospice patient out if they fell and we suspected a fracture. This is the situation the family was concerned about because he has a hx of falls.

Thank you guys for the advice. It was just a whole bunch of mess and stress for me. The whole discreprencancy of the assistant of nursing telling me she is DNR then the nurse that takes care of the paperwork telling me she is still consider full code until further signatures to be completed. It was an emergency case so I didn't have time to run and look over the chart over and over again. I had look over it a few hours prior to make sure she was still full code. I was just confused because the doctor did sign his name and put DNR under an order. However, he wrote it in one of those receipts where you tear off form. It wasn't an actual out-of-hospital DNR order form. The last DNR flowsheet that was under advanced directives was way back in 10/19/2011 and it still listed (I want CPR done) checked with the nephew (the patient's nephew) signature. So the place where I work at didn't update the files. It was just a whole lot of stress. I barely got any sleep worrying that I might get in trouble.