"She’s a DNR"

To anyone in the know,

Is there still a distinction made between DNR vs. DNI? (do not resuscitate vs. do not intubate).

And if there is…does a DNR also imply DNI?

Pepsi-loo(ny):

It’s attitudes like yours that make caring for elderly nursing home patients so difficult. Sometimes, unfortunately, hospitals reinforce that attitude to families.

Let me give you the typical scenario of NH-ER transfer:

94yo woman in nursing home develops a fever, PCP orders a chest-x-ray, urinalysis/culture, possibly blood cultures, other bloodwork, and maybe empiric antibiotics (depending on how sick she looks). Then the workup comes back over the next couple of days & is acted on appropriately. During this time, sometimes families will demand hospital transfer, despite a DNR & explanation of futility in transferring her.

Then in the ER, an intern, nurse, tech or some other unknown in a white labcoat in the ER validates the family’s improper assumption that the patient has been ignored (“damnit, this lady is sick as a dog – why did they wait so long to send her?”) The patient gets sicker & dies, which is very NATURAL for being 94 w/pneumonia. Family sues the NH for wrongful death (can’t you just see John Edwards saying exactly what YOU did? “they let her have a fever of ONE-HUNDRED-FOUR-DEGREES-FOR-FOUR-DAYS-FOLKS-IT’S-DESPICABLE!”)

So in short, you assume that nursing home staff & doctors do nothing but let people get sick & die??? This attitude (& lawyers) is what drives inappropriate ER transfers for patients that are fated to die of pneumonia/sepsis/MI/end-stage-alzheimer’s dementia/etc.

In a good nursing home (e.g. mine) we have patients on IV vanco/imipenem, VAC dressings, etc. We have a fully staffed vent unit & even a patient on a dobutamine drip! And most patients & families are realistic, after living at the NH for years becoming like family to the staff, and ultimately prefer to die at NH than some cold ER. But there are always going to be unrealistic folks, & sometimes those just looking for a payday.

What is MOST sad about this story is not that this poor woman died, but WHERE she died – in an ER surrounded by strangers. And part of that is because of your all-too-prevalent attitude that nursing homes ignore their patients.

I am impressed how WhiteCoat handled this situation and appreciate how difficult a scenario that can be – he is a true asset to the ER community.

“Why did they allow this elderly woman to have a temp of 104 F for 4 days”?

The nursing home was colder than the ER. Have they never heard of compassionate nursing care in this home, or is it staffed strictly by nurse’s aids at a salary level of $6.75/hour?

Have they no respect for the human soul?