Do Not Resuscitate: Myths vs. Facts in Nursing Homes
What do you really know about “Do Not Resuscitate” orders in nursing homes? Myths abound, but the facts are critical for making informed decisions about end-of-life care. Misunderstandings can lead to significant emotional distress and legal complications. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Ms. Cindy Neese to debunk common misconceptions and shed light on the truths of DNR orders, providing clarity and guidance for families navigating these tough choices.
NEESE:
One, it should be in their medical record. It is something that you should be able to quickly find. Some still use bracelets that will let them know that this resident, should they be in an activity somewhere, it’s always in best interest to reverify that information during the episode as well. But things happen, things.
SCHENK:
Yeah, everybody, welcome back to the Nursing Home Abuse podcast. My name is Rob. I will be your host for this episode. We have a fantastic, interesting episode this week For you, it’s all about do not resuscitate DNR. What does it mean? What does it not mean? But we’re not having that conversation alone. We had the terrific.
Nurse of multiple decades of experience, Cindy Neese with us today to talk about DNRs and what it means for you and your family.
Alright, enough. With that, Tom Fuller, it’s time to get into the meat and potatoes of the episode. As I mentioned, we’re talking about DNRs. Do not resuscitate what that means in terms of the care that your loved one will receive in a nursing home. But we’re not doing that alone. I. For today, for this week, we have the fantastic Cindy Neese.
Cindy Neese is a registered nurse with over 40 years of experience. She spent more than 30 years improving long-term care. She has held leadership roles from director of nursing to VP of clinical services and own a management company, a nationally recognized speaker and legal nurse consultant. Cindy helps attorneys navigate complex healthcare cases.
Discover specialized legal and healthcare consultation services at Neese Legal Nurse Consulting.
Her deep knowledge of nursing home operations and regulations, insurers, advocacy for residents and excellence in skilled nursing facilities, and we’re so happy to have her on the program today. Cindy, welcome to the show.
Connect with C.L. Neese Consulting, LLC on LinkedIn for professional updates and insights in healthcare consulting.
NEESE:
Hi Rob, and thanks for inviting me.
SCHENK:
Hey, you’re very welcome. I’m glad to have you on.
What exactly is a DNR? What is Full Code?
I know that I often get calls from the family members of. Nursing home residents who are confused about the concept of DNR do not resuscitate what that means when there is some type of event in, in, in the resident’s life and what the facility’s responsible for or not responsible for. And this is something that I definitely wanna talk about for a while.
So let’s just start very broadly. When we say such and such a resident is A DNR, what does that mean?
NEESE:
What it usually means is that the resident or the resident and their family have had a discussion with their physician who is attending to their care in the facility and has expressed that they do not want any heroic measures taken.
At the point in which their heart rate or their respiratory breathing stops. And if the physician has this discussion with them, which they should then this is documented. And then he writes an order that says, do not resuscitate. And that is an order that lets the staff know that this resident has chosen.
To not have CPR should they basically die.
Does a DNR mean my loved one won’t receive any medical care?
SCHENK:
So if I understand you correctly, what we’re talking about essentially is a document that says when breathing stops, when heart stops, no more medical care.
NEESE:
Correct.
How does a nursing home know a nursing home resident is DNR?
SCHENK:
In your experience, and that’s typically gonna be something that is, is discussed with the physician or with the facility, like typically, how does that document come about?
NEESE:
Oh, it can come about in, in several ways. Actually. When a resident is admitted to a skilled nursing facility, the first assessment of that resident should include. Questions to the resident about, do you have any advanced directives in place, and do you have any request about how you would like for us to handle things if you were to suffer an event where your heart stops or your respiratory or breathing stops?
And in that case, that assessment is made, it’s documented. The physician is involved. And we go from there as far as obtaining, if the resident chooses not to have CPR which is cardiopulmonary resuscitation, if they choose to not have that, then it is documented and the physician writes the order for the facility to carry out.
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NEESE:
That document is something that can be shared amongst other healthcare providers as well. Say the resident has to go to the hospital, or especially for a dialysis resident, it’s extremely important that the facility and the dialysis unit or sharing document, and that is certainly one of ’em.
So that while the resident is outside the facility, if that’s the case at the dialysis unit. The dialysis staff and nurses understand what the resident has requested and what the physician has ordered
SCHENK:
when, so a DNR order is not gonna be something that just pops into existence. In other words, like it is not gonna be the case that, okay, grandma is now 90 and so therefore it automatically trans, she transitions from full code to DNR.
NEESE:
No, as a matter of fact, it’s quite the opposite. If there is no DNR order, then the facility has no choice but to activate CPR regardless of age or condition, there must be a DNR or a DNR order, and it must be something that the re request the resident has requested previously.
SCHENK:
And you mentioned a minute ago that it’s important for the nursing home to share information, specifically the DNR documentation with other providers such as the dialysis clinic.
If the individual resident is getting dialysis, why is that important?
NEESE:
Everybody needs to be on the same page with knowing what it is that the resident has requested. It’s left to all healthcare providers to ensure that should anything happen, such as the heart rate or the breathing stop, they need to know what to do.
And if there’s no existing DNR order, then automatically they’re going to do the CPR. But if there is one, then they realize that the residents requested that’s not something that they want. If their heart stops or their breathing stops.
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SCHENK:
Typically, and I understand that every situation is different, but typically how, and we’ll start at the nursing home first.
Typically, if the resident is in the nursing home and their breathing stops or their heart stops, what’s the process typically by which the nursing home. Figures out if they’re DNR or not.
NEESE:
Hopefully Rob the facility has policies and procedures in place that will let the staff know and that are trained to let them know how that’s communicated amongst them.
One, it should be in their medical record and it is something that you should be able to quickly find in the physician’s orders. A lot of facilities do things differently when it comes to knowing how to communicate this information amongst staff. Some still use bracelets that will let them know that this resident, should they be, in an activity somewhere away from the main treatment area.
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If something emergent happens that requires CPR, they need to know then. What they should be doing, whether to initiate or not. And so some do that. Some keep it on what they call their little code cart or crash cart, so to speak. Where they can quickly access that information. Usually it’s an alphabetical list and it’s a copy of the actual order itself from the physician, but it’s always in best interest to reverify that information during the episode as well because things happen, things change and you’re dependent upon human people to.
To make sure that they follow all the steps in the pursuance. Just there’s a orders that are part of that care plan, but it actually should be distinctly on their stating that the resident has an advanced directive or they have a do not resuscitate order.
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SCHENK:
So I guess then the idea is that the policy and procedure.
The nursing home has in place is something, whether it’s a bracelet, whether it’s a sign on the door, whether it’s a, some type of cheat sheet that they can quickly understand the DNR status of an individual resident, because, time is of the essence. If the, if I think their DNR, but they’re really not.
You’ve wasted precious seconds, right?
NEESE:
Absolutely. Your response needs to be immediate. If they’re a DNR, obviously, there’s no response at that point, but if they’re not a DNR or they do not have a DNR, then immediate response is valuable. When you’re doing CPR.
Can a DNR order be changed?
SCHENK:
So a lot of times as you mentioned, clinical conditions change baselines can improve, baselines can, decline.
Is it possible if your loved one is a DNR? Can you change that? Can you say, you know what we, we see something different about our loved one and we want to get them off of DNR. Is that something that’s possible?
NEESE:
President himself, him, or herself, can absolutely verbally revoke that DNR at any point in time that they choose to, and that’s something that the staff should be educated on because that does happen.
And, people think it’s a very personal decision to make this choice. And they think that they’re ready for it and they’re okay with it. And then when something happens, they find out they’re not. So a lot of times residents will see themselves declining and they will say, I want you to make sure that you do everything possible to keep me alive.
At which point in time the staff, will need to confer. Okay. Mr. Smith you have a DNR order that says, we’re not going to do CPR if your heart stops or your breathing stops. Are you saying you now want us to do the cardiopulmonary resuscitation for you, the chest compressions and the breathing for you?
If your heart or respiratory rate stops and if he says yes or she, then the staff must react appropriately. And of course, letting everybody in the loop know, including the physician, that this has changed. And Rob, you mentioned the point about, significant changes in condition. The regulations that govern the skilled nursing facilities.
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Actually it’s the interpretive guidelines that’s there for the surveyors who actually come in and monitor the facilities and do conduct the surveys. It’s guidelines for them. And in there it states very clearly that the facilities, policies, and procedures and actions should routinely look at this with the resident.
Talk to this, talk to the resident about this decision. And make sure nothing has changed. You’ve, I’ve seen folks who come into the nursing home and they’re not in good shape and, they have given all hope for getting any better. And, they have made themselves a DNR, they come in, they do well in the facility, they receive routine medications, they get the care that they need and they improve.
At which time, that shouldn’t be something that the resident has to tell us. We as providers should recognize that there’s a significant improvement and we should say, Mr. Smith, we probably need to have this conversation with you again to see if anything has changed since you’ve done so well here, and give them that opportunity to address that with staff again.
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SCHENK:
I think that the concept is pretty cut and dry. DNR act fast. Confirm DNR, and then that’s it. There’s no medical care provided if the heart stops or the breathing stops, but we live on the edge. There’s gonna be instances in which there’s perhaps confusion and perhaps we can shed some light on that.
So are there any instances in which there’s a conflict between the DNR and what it means to stop breathing? For example, in instances in which the individual person has stopped breathing because of an obstruction. Their vocal cords or not vocal cords, but in, in their esophagus. In other words, they’re aspirated or choked.
What about then, have you dealt with that in your experience?
NEESE:
Yes. That is something that happens prior to death. DNRs are decisions after death has happened. They’ve made ’em before death, but once death occurs, it’s done, like you said, that’s it. But an emergent situation does not preclude the staff from not providing the treatment they need.
Nobody planned to have, a choking episode while in the dining room, so you might have to do a HomeLink maneuver. Of course this is something that you know, and it is not just that Rob, you do have to. And I tell residents and families this all the time I really encourage you to get involved with the residents care, and I know you’re expressing you want a DNR, but a DNR only kicks in once death has occurred.
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Everything up until that point. We have nothing that says the resident doesn’t want to receive routine medical treatment. So unfortunately though, Rob, and this has been a problem, I’ve been doing this for about 40 years and this has always been an issue at different varied times and places, not just nursing homes, where someone looks at the record and go, oh, they’re a DNR.
We’re not gonna do, we’re not gonna put them on that antibiotic, or we’re not going to put them at the oxygen, or we’re not gonna do X, Y, Z because they’re a DNR. And that’s not what a DNR means. A DNR again, only occurs at the point of death.
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SCHENK:
That’s very well stated. I think that sometimes gets lost.
In the shuffle, not just with providers, but with family members. Oh, grandma’s a DNR. Like what are we doing here? Like perhaps confusing hospice or palliative care? I. With long-term care with an individual that happens to be DNR, that’s an excellent distinction. I guess I’ve never really had it, I’ve never been focused on that, in that, thinking about it in that way before.
But that DNR doesn’t mean that you don’t, that you don’t get treated for a wound or that you don’t, receive antibiotics if you have an infection, these type of things. It’s only when X, Y, or Z happens, which is the fact that, or which is. Breathing stops, heart stops. But I guess for me, I guess the issue, and it makes sense that there are mechanisms in which, for example, the breathing stops, but only because of something that’s not natural.
And that’s when there’s, in my experience, there’s confusion about, then the facility, didn’t have to do anything because. The breathing stop. The breathing stop because there’s a big chunk of broccoli in the person’s esophagus.
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What should families know before signing a DNR for a loved one?
SCHENK:
What kind of advice would you give Cindy to family members who perhaps they’re just learning about this concept. They got a loved one that, that might be a candidate for this, that can’t, that their loved one is not verbal. Their loved one is perhaps has dementia, is not cognitively, can’t make that decision. The family has to make the decision.
NEESE:
What should they take into account, their residents wishes and any discussions that they might have had with that resident earlier on.
That’s whether we’re acting as a healthcare provider or we’re acting as a family member, the whole goal is to honor the resident’s wishes. And if Mother told you that she absolutely wants everything done, and she wants to do what she can to stay alive. Then, that daughter is going to, we’re going to encourage those doctor daughters to remember those conversations.
But Rob I try to tell families all the time, even my own and my parents, don’t wait till something happens to have to worry about that, and we have a thing, what we call advanced care planning as well. Where we, we see someone is declining then we need to bring the family in and the resident and the physician and we all need to have a discussion about here’s what’s here or may not happen.
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And then maybe go ahead and formulate something you can never force a resident to make an advance directive or to do a DNR. Absolutely has to be their choice with the family. And we also encourage the family to go ahead and try to get something. If they’re worried about I don’t know if this is the way mom wants or Mom wants it this way, but I don’t know if my sister would agree.
We encourage the family to work that out together. And if that can’t be worked out, then we encourage, you, know, them to maybe let the courts decide before that happens so that someone can make that decision and act in the best interest of the resident. And just because somebody is the residents res representative doesn’t mean that they can say I don’t want mom to have this, or, I don’t want dad to have this.
If the facility feels that family member is not acting in the best interest of that resident as far as keeping in mind what the resident would have wanted, then they’re supposed to step up and still be that advocate for that resident.
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SCHENK:
Very well said. Cindy, I really appreciate you coming on the show with us this week and sharing your knowledge with us.
Thank you so much.
NEESE:
Thank you, Rob. I’ve enjoyed it. It’s my pleasure.
SCHENK:
Folks, I hope you found this episode informative. If you enjoyed the episode, be sure to like and subscribe wherever you get your podcast from. If you have an idea for a topic that you would like for me to go over, please let me know.
If you have an idea for a potential guest that you would like for me to talk to, please let me know that as well. New episodes of the Nursing Home Abuse podcast come out every single Monday. With that folks, we’ll see you next time.
Ms. Cindy Neese’s Contact Information: