The DNT Order??

Tonight I would like to take a few moments to hit on what is one of my top-ten all-time use-a-lot-of-dashes-in-between pet-peeves in EMS and probably in health care in general. It’s the “DNT” or “Do not Treat” order. It might just as well be called the “DNC” or “Do Not Care” order, or “Do Not Comfort”, or “Do Not Be Humane”, “DNBH” Order.

Yes, I’m talking about DNRs here. They’re “Do Not Resuscitate” orders and if you’ve been in EMS for longer than a minute or two you’ve heard about them.

DNRs serve a good, humane purpose in a lot of cases. We all know that even though we’re improving (GO CCR!!) CPR and ACLS are largely rituals that we perform for the dead in our society. They rarely bring people back if they happened to be sick enough to die in the first place. They’re also very traumatic things to do to a body. DNR Orders are a humane way for patients and families to say “Enough. When God or whom/whatever I may or may not believe in says it is my time, it is indeed my time”. I can respect that. I happen to be a Christian and I believe that we go to a better place once God decides that it’s time to punch our clocks. If I had a hopelessly terminal disease I would probably be pretty ticked off if some young kid with a shiny new EMT card brought me back to face more of the disease progression with a couple of broken ribs for the trouble. I get it.

What I don’t get, and what just drives me crazy is people who treat DNR orders like they’re “DO NOT TREAT THIS PATIENT BECAUSE THEY’RE JUST A DNR” Orders. I know that I will hear this again, and probably tomorrow because I heard it three times today and I’m on a 48hr shift here, but I think that I might say something unkind to the next person that says, “well.. They’re a DNR” when I ask them why they’ve let their patient suffer in agony for hours before they decided to send them to the ER. Yes, I um… occasionally go to “Skilled Nursing Facilities”, can you tell?

Here’s what a DNR order does NOT mean:

  • It does NOT mean: Let your patient be Hypoxic – Yep, I can see that they probably don’t want you sticking an ET tube down their throat. BUT PUT THEM ON OXYGEN IF THEY ARE HAVING TROUBLE BREATHING!! HELLO!!?! WOULD YOU WANT TO LAY THERE WITH A PULSE OX OF 80 SOMETHING!?! IT’S CALLED COMFORT CARE!!!! ; Ahem, sorry… but good patient care is one of my highest goals. Please, on behalf of everyone who does not want to go through the agony of suffocating in their own body, please do things to maintain a patent airway and good oxygenation. Please.
  • It does NOT mean: Wait until a simple medical problem is something critical before you seek a higher level of care – For the EMTs/Medics in the audience (if I ever get one.. Tell your friends!! J) how many times have you walked into a patient’s room at a “Skilled Nursing Facility” and found that only when a patient’s family member came to visit and found grandma gorked out did the staff think to maybe do an assessment on them. Treat every patient the same, give them all the same level of care, just don’t pump on the chests of the ones with the DNRs! Simple, right?? Don’t let them get septic from a UTI. Don’t let them get pneumonia from a simple cough. Don’t… forget that we’re all deserving of human comfort.

  • It does NOT mean: Let your patient die of dehydration and/or starvation – This goes back to being humane. Really… Yes, I have see this, treated it, and taken care of it but I don’t see the point in saying why or where. (Remember, I’ve been a lot of places in the ten odd years I’ve been in the back of a bus). Every human being needs to eat and drink some way, somehow to keep from dying a horribly painful death. Don’t neglect people because they happen to have made a decision to not have CPR done on them.

Don’t think that I’m just picking on the nursing homes here.

I once had a transport where I took a young infant with a horrible medical condition from a small ER to a tertiary Childrens’ Hospital. (A different one from the one in a previous post). This poor little baby was now living with a set of very nice foster parents but just didn’t seem to have much chance in the world due to his/her terrible start in life. The child was on oxygen, needed regular suctioning, and was being sent to this tertiary facility to replace his/her feeding tube, which had become dislodged. Because of that, the patient was having some increased breathing difficulty and was actually pretty challenging to take care of for the hour long transport. The foster mother had brought the baby into the pediatrician’s office for this condition, and the pediatrician had set up the direct admit to the tertiary facility after sending the kid to the ER close to his office.

The foster mother was a very nice lady who seemed genuinely concerned and caring about the kid. I asked her why if the kid was in that bad of shape did she not call 911. Her answer? “I thought I couldn’t call 911 because he has a DNR order”. Someone, and I don’t know whom… but someone had told this wonderful foster mother that this child was NOT WORTH EMERGENCY CARE because he had a DNR order! Yea, not in so many words I don’t think… but that’s the general idea she had. I corrected it. Told her to call 911 whenever she felt she needed to and let her know that the ambulance crew where she lived would love to come visit her to learn about and help take care of the child. I cannot believe that someone would lead a person to believe that… I just can’t.

Oh, and yes, today I had a SNF patient that fit my whole DNR/DNT pet peeve thing… and yes, an ER staff person may or may not have given the “Just a DNR” comment. In fact the whole healthcare system may have failed someone today that chose to have a DNR order and neither he/she nor his/her family knew about it. But I did, and I fixed it.

And I just ranted about it.

Someday soon I may turn this blog post into a coherent article, got any rants you’d like to post? I like comments. As always:

  • Charlieb

    Good rant. I hope those who believe DNR = DNT take the time to read this and give the issue some thought.

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  • CJ

    Actually, hydrating or feeding a person whose organs are shutting down is not compassionate. If you don’t make urine and some idiot ‘rehydrates’ you, you now have fluid overload. Ya really want dialysis to remove that fluid? If you put nutrition into a GI tract that no longer functions, you get bloating, nausea, reflux and maybe aspiration for your trouble. If you start TPN, you need a central line, risk infection and hyperglycemia, and once again, fluid overload. When thirst and appetite are gone, you don’t need to replace anything. It’s just part of the journey and people in that state have never complained to me of hunger. Mouths can be moistened with a swab.

  • Random_Medic_Student

    Not to dig up an old thread, but i am bringing this article into the paramedic class im in. I may as well do my research paper on it.

    Thank you for the wonderful rant.