Monday, August 23, 2010

DNR Orders: Wearing the bracelet

Having informed, compassionate discussions regarding goals of care and resuscitation status takes a lot of effort on all parties involved.  But despite all the articles and advice about 'breaking bad news' I have not seen anyone formally discuss the very sensitive act of placing a DNR bracelet on the patient.



Lisa Calderone-Stewart writes about the DNR* bracelet and what it means to her at the US Catholic blog 'The Examined Life.'**  (You can find other posts just by her at 'Final Thoughts')  She enrolled in hospice and is still very active going to the YMCA and chiropractor visits..  She realized being out of her house she may not always have the appropriate documentation on her person, so she purchased a 'Medic Alert' bracelet:

Other people have such bracelets declaring the person is allergic to penicillin or diabetic; mine says, "NJ, WI DNR Order on File. DO NOT RESUSCITATE." It also has my name, my DNR ID number, and a toll-free number someone can call if they are confused about the instructions.

Some accept it without any difficulty, others must look at their policies and alert their staff about the need to check all people for DNR bracelets prior to instituting resuscitation efforts.  As I did some online research, I realized many states have particular companies who will make 'DNR jewelery.'  Good to know!




For patients in the hospital, the placement of the DNR plastic bracelet (or sometimes a purple clip on a bracelet) is often an afterthought without much ceremony nor consistent education.  Imagine yourself in the patient's role, after a long exhausting discussion (or a brief, confusing short one) about your medical condition and plan for care in the hospital, a nurse walks in 20-30 minutes later and places the bracelet on your arm.  Maybe the nurse offers an explanation of what it is, maybe not.  You ask about this new purple bracelet.  "It's the DNR order from the meeting you just had with the doctor."  "Well I don't want this," you reply.




I have found without explicitly discussing the act of placing the bracelet, many goals of care discussions have been completely undermined. So now our team makes a point, even thinking of it as a 'check-off' in the wrap-up phase of a family meeting to make sure the bracelet is explained to the patient and the family.  Interestingly on occasion discussing this has led some families to actually refuse placement of the bracelet often in fear of upsetting the patient.  This of course leads to sitting down and having more discussions.

Do you have any tips about working with DNR bracelets?



*All mentions of DNR imply Do Not Attempt Resuscitation or DNAR, but DNR is used here as convention. AND if you want to talk about using AND (Allow Natural Death) as a medical order instead of DNR you can see this earlier post.
**Blog post found via @MeredithGould on Twitter

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