When a patient’s decline hastens, it is good for all to know for sure whether she would want to die naturally. Nurses have called me on Saturday afternoons for helping finding DNRs, either to confirm one exists, or so that it can accompany a patient to a hospital or nursing home.
DNRs are crucial documents, so I would respond to DNR questions by heading into the office so that I could confirm whether one existed. I eventually simplified my life with a systematic approach to managing DNRs and informing the team about a patient’s DNR status.
These are the conditions to have in place with regards to DNRs:
- All patients and family members will understand well the ramifications of the decision whether or not to have a DNR.
- Each patient who wants a DNR has one.
- Every DNR is correctly filled out.
- Each member of the hospice team is able to easily confirm whether or not a patient has a DNR.
- You have reliable access to each patient’s DNR at all times.
And these are the steps for a hospice social worker to take towards meeting this conditions:
Step one: Look for a DNR when a patient is coming on board.
When a marketer or nurse has his initial meeting with a patient, the topic of DNRs most likely comes up. Find out if they received a DNR or how the patient/family member responded to the topic.
Step two: Confirm that new patient’s DNR is valid.
Different states do DNRs differently. They are a little complicated in Texas, and quite frequently they are filled out incorrectly. Redoing them requires either two witnesses or a notary. Knowing sooner about incorrectly filled ones gives you more of a head start on planning with the patient or family to have it redone.
Step three: Educate patients about DNRs and facilitate completion
When patients don’t have a DNR, have this discussion as part of your initial assessment. Help them understand what it means and the reasons why many choose to have one. Have this discussion without assuming that it is best for them. It is up to them.
Step four: Inform the whole team DNR.
After your initial assessment, email the team to let them know and announce any new DNR statuses during the IDT meeting. At one agency, the intake coordinator was responsible for updating the active patient list. After every assessment or completion of a new DNR, I would send out an email to the whole team with “DNR – Last name, First name” in the subject heading to make it easier for her to know to update the list.
Step five: Keep a copy of each DNR in a separate binder.
This is separate from the patient chart and mostly kept to yourself. Documents can mysteriously disappear, and a disappearing DNR can be bad news. When I first started keeping a binder, I’d get calls when DNRs would turn up missing from patient charts. I’d tell them to look in the binder in my office. A couple months later, I got a call from the same person saying that she couldn’t find a patient’s DNR in my binder. I’ve no intention of theorizing about how they got lost, but I do believe that keeping a binder secret is a good way of preventing crucial documents from vanishing.
This marks the conclusion, for now, of our discussion of DNRs, advance directives and powers of attorney. I hope you found it useful. When we return, we’ll look at compassionately and ethically prompting patients and family members to discuss funeral homes.