6.8.1 The effect of do-not-resuscitate orders on the care plan of critically ill patients (129)

Maria Angeles Margall, Nurse Manager, Intensive Care Unit, Clínica Universitaria de Navarra, Pamplona Navarra, Spain Co authors: Carrion Asiain, Zubizarreta E & Sarasa MM mamargall@unav.es

Abstract:

Background:

Do-not-resuscitate (DNR) orders are physician orders not to initiate cardiopulmonary resuscitation on a patient who is in cardiac or respiratory arrest; however, these orders often imply other treatment modifications.

Aims:

To analyse the effect that do-not-resuscitate orders have on the care plan of the critically ill patient; and to analyse if differences exist in the nursing workload (NEMS), before and after DNR prescription.

Method:

This descriptive retrospective study was carried out in the 12-bed surgical-medical intensive care unit of a Spanish teaching hospital. The computerised care plan from 73 patients (p) who had a DNR order written in ICU over a 21-month period was analysed (2005-2007). Data collection included: demographic data, therapeutic plan, physicians’ and nurses’ progress notes, family participation in the decision making, length of family visits, spiritual support and NEMS.

Results:

After the DNR order some therapy was withdrawn in 41p, initiated in 8p, both withdrawn and initiated in 13p, and in 11p therapy remained unchanged. Specific modifications: mechanical ventilation was withdrawn in 13p, and the FIO2 was reduced in 19p on the day of death; vasoconstrictor drugs were withdrawn in 18p and initiated in 2p; inotropic drugs were withdrawn in 7p and initiated in 2p; haemofiltration was withdrawn in 10p and initiated in 2p. Family daily visit was recorded in all patients. In 61 of them, relatives spent several hours a day with the patient and in 20 patients, family participation in the decision making of the order was documented. NEMS scores decreased on the patients after the DNR order (35.64-32.67; t=3,363, p=0.001).

Conclusions:

Do-not-resuscitate orders have an effect on the care plan of the critically ill adult patient. Also, although NEMS scores decrease after the order, nursing workload do not diminish due to an increase in the psychosocial needs of patients and families.

Recommended reading list:

  • Simpson, S.H. (1994). A study into the uses and effect of do-not-resuscitate orders in the intensive care units of two teaching hospitals. Intensive and Critical Care Nursing, 10(1), 12-22
  • Chu, W., Hynes-Gay, P. (2002). The influence of DNR orders on patient care in adult ICUs: a review of the evidence. Dynamics, 13 (4), 14-21
  • Sulmasy, D.P., Sood, J.R., Ury, W.A. (2004). The quality of care plans for patients with do-not-resuscitate orders. Archives of Internal Medicine, 164(14), 1573-1578

Source of Funding: N/A

Amount in Funding: N/A

Biography:

Recent publications: Del Barrio M, Jimeno L, López P, Ezenarro A, Margall MA, Asiain MC. Cuidados del paciente al final de la vida: ayudas y obstáculos que perciben las enfermeras de Cuidados Intensivos. Enferm Intensiva. 2007; 18(1): 3-14. Aizpitarte E, Garcia de Galdiano A, Zugazagoitia N, Margall MA, Asiain MC. Ulcères de pression en soins intensifs. L’escarre. Revue Officielle de l’Association PERSE. 2006; 32:25. Marco L, Bermejillo I, Garayalde N, Sarrate I, Margall MA, Asiain MC. Intensive care nurses’ beliefs and attitudes towards the effect of open visits on patients, family members and nurses. Nurs Crit Care. 2006; 11 (6):33-41. Professional and academic experience: Since 1990 - present, ICU nurse manager. University Clinic of Navarra. University of Navarra. Pamplona, Spain. Since 1989 - present, associate lecturer in Intensive Care and Research. School of Nursing. University of Navarra. Pamplona, Spain. 1997-1999, Master in Nursing Science. University of Montreal. Canada. 1981-1983, Specialisation course in Critical Care Nursing. University of Navarra. Pamplona, Spain. 1980-1990, staff nurse. ICU. University Clinic of Navarra. University of Navarra. Pamplona, Spain. 1979-1980, staff nurse in a surgical ward. University Clinic of Navarra. University of Navarra. Pamplona, Spain. 1976, Nursing Diploma. School of Sta. Madrona. University of Barcelona, Spain.