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DNR codes can be a tricky order for nurses to carry out when a patient takes a turn for the worse. To streamline the decisions made by healthcare professionals after the order is in place, nurses at The Valley Hospital in Ridgewood, N.J., came up with a three-tiered system.

But to get to that point, the team realized it first had to overcome two challenges. “We needed to create a special code status form that would stay in a specifically identified area of the patient’s chart,” says Tina Basenese, RN, APN-C, ACHPH, coordinator and nurse practitioner of palliative care services at The Valley Hospital. “And we needed to establish a care plan that is clear to the physicians, the staff, the patients, and the families.”

In response to the issue, a hospital-wide palliative care program was developed, code status orders were examined, and two key issues were identified, Basenese says. The first issue with code status was the problem of defining DNR. “We surveyed the nursing staff,” Basenese recalls, “and realized that there were many conflicting, personalized opinions.” From hospice-type comfort care to full treatment including surgery and dialysis, nurses described DNR care differently.

The second concern was that DNR orders were not always readily available. “The DNR orders were written among all of the other medical orders and didn’t always follow the patients through their stay in the hospital,” Basenese says. “We realized that we were often relying on shift-to-shift reports to relay code status information.”

The Process

The palliative care team, under the direction of Basenese, realized they needed a better way to address code status in 2004. “We started off by contacting other hospitals to see their DNR policies and forms,” Basenese recalls. “What we found was surprising. Many facilities didn’t have any kind of specialized forms or policies, some had forms that were more like advanced directives, and others had a page with a DNR written in large letters that was placed in the chart.” The group looked at stickers that could be put on charts, wrist bands, and signs placed over the bed. The findings were presented to Valley’s legal department but none were acceptable because of patient safety and privacy concerns.

By reviewing the strict definition of DNR, the team developed a tool. Basenese started on a process that involved initial drafts and templates, presentations at high-level hospital meetings, critiques, criticisms, rewrites, and meetings with key physicians who would most likely be working with the new tool. “It was a massive blitz,” Basenese says, “with education, re-education, meetings, and three redrafts over three years.”

The Product

What developed from this three-year process is a unique one-page code status sheet that not only defines the patient’s specific code status but also encompasses the physician progress note with an explanation of who the physician talked to and whether the patient has an advanced directive. The code status form is used throughout the hospital, and though every patient is eligible, usually less than 10% of the patients have code status orders. “For those patients and families who are concerned about resuscitation efforts, we now have a one-page form that spells out three code status categories and three different plans of care,” Basenese says.

@Sibebar bullets:DNR A is a comfort care treatment plan where medical treatment is aimed at providing relief from pain and suffering with no intubation and comfort care only, similar to hospice care.

DNR B is DNR with a therapeutic treatment plan in which the patient continues to receive therapeutic treatment for all medical conditions except in the event of cardiac arrest.

DNI directs healthcare providers to continue to provide therapeutic treatment for all medical conditions except endotracheal intubation.

On the Same Page

To maintain consistency, nurses attend a palliative care resource class. At the beginning of the class, nurses are asked what they would do if a med/surg patient with a DNR order becomes bradycardic and hypotensive and is clearly symptomatic. “Typically, the class splits in half,” Basenese says. “Half of the nurses say they would transfer the patient to critical care, the other half says they would not.”

At the end of the palliative resource class, Basenese presents the patient scenario to the class again. First she presents it as a patient with a DNR A and asks what they would do. The nurses say they would not move the patient but look at additional ways to provide comfort. Then she presents the same patient with a DNR B order. The nurses respond the patient should be moved to critical care to treat the heart arrhythmia as well as the hypotension.

The new system has provided a clearer understanding for healthcare providers on what a DNR order means, and it has provided a starting point for conversations with patients and their families. “The new orders give us more latitude in the treatment plans,” explains Birte Mainardi, RN, BSN, holistic and palliative care nurse at Valley. “When a patient is ill and unsure of the outcome, he or she can choose to have a DNR B and still receive treatment. If they decline and choose not to receive any further treatment, they can transition to DNR A. The plan takes away the family’s fears that we have written off the patient because they have a DNR order.”

Palliative care advanced practice nurse Linda Gurick, RN, APN-C, agrees. “The code status form takes away the confusion. I can explain the treatment that is involved in both levels of care,” she says. “As a former hospice nurse, I appreciate that we can offer patients the DNR A and initiate that level of comfort care and follow through with it in the hospital setting.”

For additional information, e-mail Basenese at abasene@valleyhealth.com.

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Carol Nelke Dunbar, APRN, is a freelance writer. To comment, e-mail editorNJ@nursingspectrum.com.