DNR Orders Overturned By Doctors

Nurses General Nursing

Published

Hi,

I am a nursing student and my husband is a RN in an ICU. He tells me that a patient will come in as a DNR and then the patients family will talk to the doctor and then the doctor will change the patients code status to full code.

Why do you think this happens? It's my understanding that if the patient wanted to be DNR, this should be respected regardless of how the family feels about it. Doesn't the doctor have a legal responsibility to respect the patients signed DNR order?

Do you think this happens because doctors don't want to have a confrontation with the family and it's "easier" to comply with the families wishes rather than have the family feel as though the doctor is "letting" the patient die?

My husband tells me that a lot of the patients in the ICU are from nursing homes, have severe dementia and are bed bound, with minimal to no LOC. It seems sad to me that they are being kept alive on ventilators against their documented wishes.

Is this legal? Is it ethical? Is it prevalent in your experiences as RN's? Or is the hospital my husband works at the exception?

Thanks for any feedback you are able to offer. I'm just sort of baffled by this issue. :o

My folks went to a lot of time, trouble and expense to exact living wills, power of attorney and DNR orders which were VERY specific. They designated my sister as POA and on both orders stated "if we are discovered unresponsive we do not wish advanced CPR, intubation or cardiac shock but comfort measures until we expire naturally". My Mom was discovered in her hospital bed by her nurse, cyanotic, pulseless and non responsive. A code blue was called and ACLS performed.

After 12 minutes a pulse was violently obtained and she was intubated and sent to ICU were she began to have seizures. There were numerous rib fractures and by the time I flew out to California from Tennessee she was actively seizing and had an NGT, FC and was in restraints causing wrist fractures. An EEG had been performed showing very little brain activity, non responsive to any stimuli and I requested to review her chart. My Dad was adament that she did not wish to be ventilated and the Neurologist confirmed that she was "brain dead" with no hope of recovery.

Her legal wishes were pointed out to the attending RN and charge nurse with many tearful requests by her family, who had all gathered at the bedside to witness this atrocity and indignity, to have her wishes respected. Her PMD was unreachable and it was 5 days of unimaginable frustration to have to visit her, explain to friends and family her condition. We were all exhausted and angered. Our protests fell on deaf ears and the ICU staff treated us all like terrorists.

5 DAYS WENT BY before her MD showed his face in her room. I am thankful it was just my son and I visiting that afternoon. I really wanted to grab him by his collar and yell into his face "Would you subject ANY member of your family to this or do you just dislike my Mom!!!" She had begun to third space, her kidneys were shutting down, she had aspirated her tube feeds and had developed stage 2 pressure sores.

5 days prior she had "passed away" and was on an incredible journey to somewhere we can only imagine, only to be jerked back to a prison sentence handed down by beurocracy and medical science in a "We know best" mentality.

This woman who had been so protective of everyone she loved, who strived to make everyone's lives happy, who always found the time to listen and comfort was dealt the ultimate cruelty, a prison she could not escape from. Endless days, hours of limbo, physical indignity and my family having to go through the desperation, the helplessness and anger of seeing her like that. 5 days went by. For us all.

Just imagine how that must feel to a teen age kid. 5 days is an eternity in the best of times. There were 6 of her grand children who saw her throughout those 5 days. Their eyes were swollen with tears, their anger mounting and no one seemed to acknowledge the injustice. They stand in a cold, brightly lit environment with strange noises, hostile people all around and hold the cold and unresponsive hand of a woman who used to soothe them, cuddle them and would look upon them with her compassionate violet eyes and cajole a smile out of them every time. With warm and responsive hands.

How do you explain this situation to them? How can they every trust a medical professional again? How do you comfort your Dad as he stands at the bedside of the love of his life, his best friend, his travel companion and someone he promised to protect for 56 years when silently he is screaming inside at every twitch of her tortured body, every beep of some intrusive machine?

Can a piece of paper that they drew up 3 years prior at a cost of 2500 bucks apiece explain this foul up? Does he stand and wonder if he too will be subjected to this if found "unresponsive"? Can anyone stop what they are doing to his wife and let her again slip away into another place, away from the cold, away from the harsh lights, intrusive treatments and having those she loved best stand by in anguish?

Was this wrong? Was it immoral, unethical, bad form to jerk her back from were she was naturally going? If so, who is to blame? How do you comfort those that clearly do not want the same for themselves at the most intimate of moments... our time to die? We are all angry at injustice. We all feel helpless and lose heart in the humanity that should bind us all together. We all want to lash out and express that anger, that hand wringing moment when the world is just too big and we are not as powerful as we thought. We are ultimately just a feather in the breeze, my Mom was, my entire family buffeted by the wind of bureacracy and "red tape".

You can "let go" and ride that breeze, or be jerked violently back to earth as my Mom was. She was something! She was in many ways my best friend, my voice of reason and so beautiful you would believe you were looking at walking art. She could take your breath away! And everything that happened to her still takes my breath away. We are, my family and I, still the walking wounded. I see them all from time to time. They are more silent, sleep less, startle easily and I see in my father's eyes a look of both grim determination and defeat. No measure of comfort from my siblings will ever restore the horror that those 5 days took from us, the beloved living survivors.

Many of her friends and family are initiating "Jeannies Law" which is a color coded arm band that we hope will be a universally recognized medical standard that is issued during every hospital admission to every patient, regardless of age, health status or ability to pay some attorney to draft a useless document on their behalf.

It will be considered as part of every patients bill of rights, to make decisions regarding their health care. Please support it when it goes public. The end of life wishes and the dignity of those choices saved might be mine.......

In order for someone to receive another's social security benefit, the person receiving the benefit must sign a form,witnessed. The direct deposit check is then deposited into that account. It is not as easy as many seem to think it is, to obtain someone else's benefit check. And the comment about people wanting 'granny' kept alive until the end of the month is just hogwash. Death and benefits are tied into a monthly cycle. Die anytime during the cycle, regardless if it is the first day or the last day, the benefit must be repaid. A death certificate must be provided to the S.S.A. Failure to do so and to continue to collect even one month's benefit is against the law. Woe be it to anyone who thinks the federal government will not come after them for just one payment.

Woody:balloons:

And yet, it happens all the time. And I do mean that. Granny being kept kicking until the end of the month and then the family receives the check isn't hogwash, and it isn't illegal. There's nothing for the government to "go after" if she was alive during the period of time that check covered. It's not as if the check is written a month AHEAD; it always covers a prior period, so therefore no one is defrauding anyone by keeping the money that covered the time period she WAS alive.

Morality is not the same thing as legality, however; obviously none of us would prefer to force Granny to stay alive if that was against her wishes. But without her wishes in place (and even when they are), this DOES happen.

dang, i posted this in the wrong thread.

sheesh.

tgif.

leslie

ROFL, I was REALLY trying to make the connection here! :D

Specializes in Trauma ICU,ER,ACLS/BLS instructor.
My folks went to a lot of time, trouble and expense to exact living wills, power of attorney and DNR orders which were VERY specific. They designated my sister as POA and on both orders stated "if we are discovered unresponsive we do not wish advanced CPR, intubation or cardiac shock but comfort measures until we expire naturally". My Mom was discovered in her hospital bed by her nurse, cyanotic, pulseless and non responsive. A code blue was called and ACLS performed.

After 12 minutes a pulse was violently obtained and she was intubated and sent to ICU were she began to have seizures. There were numerous rib fractures and by the time I flew out to California from Tennessee she was actively seizing and had an NGT, FC and was in restraints causing wrist fractures. An EEG had been performed showing very little brain activity, non responsive to any stimuli and I requested to review her chart. My Dad was adament that she did not wish to be ventilated and the Neurologist confirmed that she was "brain dead" with no hope of recovery.

Her legal wishes were pointed out to the attending RN and charge nurse with many tearful requests by her family, who had all gathered at the bedside to witness this atrocity and indignity, to have her wishes respected. Her PMD was unreachable and it was 5 days of unimaginable frustration to have to visit her, explain to friends and family her condition. We were all exhausted and angered. Our protests fell on deaf ears and the ICU staff treated us all like terrorists.

5 DAYS WENT BY before her MD showed his face in her room. I am thankful it was just my son and I visiting that afternoon. I really wanted to grab him by his collar and yell into his face "Would you subject ANY member of your family to this or do you just dislike my Mom!!!" She had begun to third space, her kidneys were shutting down, she had aspirated her tube feeds and had developed stage 2 pressure sores.

5 days prior she had "passed away" and was on an incredible journey to somewhere we can only imagine, only to be jerked back to a prison sentence handed down by beurocracy and medical science in a "We know best" mentality.

This woman who had been so protective of everyone she loved, who strived to make everyone's lives happy, who always found the time to listen and comfort was dealt the ultimate cruelty, a prison she could not escape from. Endless days, hours of limbo, physical indignity and my family having to go through the desperation, the helplessness and anger of seeing her like that. 5 days went by. For us all.

Just imagine how that must feel to a teen age kid. 5 days is an eternity in the best of times. There were 6 of her grand children who saw her throughout those 5 days. Their eyes were swollen with tears, their anger mounting and no one seemed to acknowledge the injustice. They stand in a cold, brightly lit environment with strange noises, hostile people all around and hold the cold and unresponsive hand of a woman who used to soothe them, cuddle them and would look upon them with her compassionate violet eyes and cajole a smile out of them every time. With warm and responsive hands.

How do you explain this situation to them? How can they every trust a medical professional again? How do you comfort your Dad as he stands at the bedside of the love of his life, his best friend, his travel companion and someone he promised to protect for 56 years when silently he is screaming inside at every twitch of her tortured body, every beep of some intrusive machine?

Can a piece of paper that they drew up 3 years prior at a cost of 2500 bucks apiece explain this foul up? Does he stand and wonder if he too will be subjected to this if found "unresponsive"? Can anyone stop what they are doing to his wife and let her again slip away into another place, away from the cold, away from the harsh lights, intrusive treatments and having those she loved best stand by in anguish?

Was this wrong? Was it immoral, unethical, bad form to jerk her back from were she was naturally going? If so, who is to blame? How do you comfort those that clearly do not want the same for themselves at the most intimate of moments... our time to die? We are all angry at injustice. We all feel helpless and lose heart in the humanity that should bind us all together. We all want to lash out and express that anger, that hand wringing moment when the world is just too big and we are not as powerful as we thought. We are ultimately just a feather in the breeze, my Mom was, my entire family buffeted by the wind of bureacracy and "red tape".

You can "let go" and ride that breeze, or be jerked violently back to earth as my Mom was. She was something! She was in many ways my best friend, my voice of reason and so beautiful you would believe you were looking at walking art. She could take your breath away! And everything that happened to her still takes my breath away. We are, my family and I, still the walking wounded. I see them all from time to time. They are more silent, sleep less, startle easily and I see in my father's eyes a look of both grim determination and defeat. No measure of comfort from my siblings will ever restore the horror that those 5 days took from us, the beloved living survivors.

Many of her friends and family are initiating "Jeannies Law" which is a color coded arm band that we hope will be a universally recognized medical standard that is issued during every hospital admission to every patient, regardless of age, health status or ability to pay some attorney to draft a useless document on their behalf.

It will be considered as part of every patients bill of rights, to make decisions regarding their health care. Please support it when it goes public. The end of life wishes and the dignity of those choices saved might be mine.......

What an eye opening post. I hope everyone who reads it remembers it in their practice. This is why I say that being an advocate for pt's and families is so important. We can make a difference in times like this. Five days before the attending came. You have more patience then me, I would have been at his door. Many will learn alot from this, you should be proud .

Specializes in icu, er, transplant, case management, ps.

I don't think it was a useless piece of paper. If it was presented, upon your Mom's admission and her appointed proxy was there, with the appropriate piece of paper, I would be seeing an attorney about sueing the heck out of the hospital. This is the whole reason for people having Living Wills and Health Care Porxy, to make their wishes known and to have someone to make the decisions when they cannot.

Woody:balloons:

I am working on medical/telemetry floor.

We are being instructed to document patient's resus status on admit.

I feel that this is premature in many cases, as many (if not most) advanced directives address patient's wishes "if they are in a terminal state".

Since the great majority of patients are obviously not being admitted to a hospital "in a terminal state", I feel that these advanced directives are being prematurely acted upon (ie DNR orders being requested from physicians immediately upon admit)

Curious to know if anyone else has had this experience?

I am working on medical/telemetry floor.

We are being instructed to document patient's resus status on admit.

I feel that this is premature in many cases, as many (if not most) advanced directives address patient's wishes "if they are in a terminal state".

Since the great majority of patients are obviously not being admitted to a hospital "in a terminal state", I feel that these advanced directives are being prematurely acted upon (ie DNR orders being requested from physicians immediately upon admit)

Curious to know if anyone else has had this experience?

It has nothing to do with their admission diagnosis, it's the law.

The Patient Self-Determination Act (PSDA) is a federal law passed by Congress in 1990 which requires providers to inform all adult patients about their rights to accept or refuse medical or surgical treatment and the right to execute an "advance directive."

The act requires all health-care institutions that receive Medicare or Medicaid funds to provide patients with written information about their right under state law to execute advance directives, but it does not require states to adopt or change any substantive laws. The written information must clearly state the institution's policies on withholding or withdrawing life-sustaining treatment.

An advance directive is a legal document.

A DNR order can only be written by a physician. You can not write a DNR order on yourself. Even people who have advance directives that specifically state they do not want extrodinary measures and do not want CPR may not have a DNR order.

A DNR order must be rewritten at each facility transfer. That is a DNR order from a SNF is not valid at an acute Hosp. The doc must rewrite it. This is the law.

DNR orders generally are written when there is no likely hope that the current condition will result in recovery and the the person is expected to die. You will not for instance see a DNR order on a person with a non terminal disease or condition. Even though a advance directive states no CPR.

With all that given, it is unfortunate that once you die you can not sue the doctor for not honoring a DNR. However, your family can sue if you die and they can convince an attorney it was from neglect or malpractice or that the person did not really want a DNR in this case or was incompetent or co-hersed into signing an andvance directivee.

Weather one wins or looses a suit it is messy and expensive.

It invites unwanted notariety.

Many doctors do not have the social fenness to talk with families and patients about this honestly.

Some times family do not agree with the pt's wishes or even know them. Some times the family is nuts.

Sometimes the family needs more time to emoationaly and cognitivaly adjust to the fact that this person is going to die.

I have seen hospice patients be prodded even forced to eat to "keep up their strength" I have seen family want to tube feed them even when on another level they know they are actively dying. The emoational irrational side will not let them die in peace

We actually just went over this in NS, and we were told that a DNR is null and void if ANY immediate family member says, "save them" (or anything of the like). I think it's horrible that a persons wishes can be overturned like that, but unfortunately it's the law (according to our nursing instructors).

if a patient does not have a disignated RP and then goes into a coma it will make for a complicated situation..some people just can't make the decision, and no doubt it is the most heart wrenching decision that you can make esp on a young accident victim

part of a nurses job is to present the facts insuch a way that the family can come to an agreed decision

Specializes in Trauma ICU,ER,ACLS/BLS instructor.

Actually, a DNR order can and should be written on admit, no matter what the diag, if the pt request it and has a document. An elderly person of 90 ,might come in for a scope and code on the table. It is what it is. When nature takes its course, a pt's rights should pervail. I know there is much controversy here, but come on, do u wanna be breaking ribs on a 80 year old, no matter why they came in?

Overturned? How about ripped in half? During my first year of work as an RN, I had a 90-something year old pt. who could not hear, see, speak, control her bowels or bladder, etc...She had constant liquid stool seeping into the various open areas/decubiti all over her body, and not a vein to be found for phlebotomy, let alone IV access. Her BP was essentially ???/palp and her heart rate was through the roof, nevermind her sats and respirations...DNR paperwork was initiated by the ER attending. Several hours later, the resident doing unit admissions decided to be Superwoman...She screamed at me for failing to obtain the impossible vascular access-which was attempted by no less than four RN's, several phlebotomists, one ER PA and TWO ER docs, then stated..."She's not a DNR you know!" I quickly advised her of all the efforts that had been made to get things rolling, and then showed her the DNR paperwork that had been completed earlier. She LITERALLY RIPPED IT UP and stormed off to the pt's bedside. How illegal is that? BTW, she never got the line...AND she couldn't even get the blood with a fem stick...Gotta love those resident heroics. Large part of why I left ER nursing.:angryfire

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