DNR questions... Family vs Patient wishes.

[MIcrunchyRN]

Ok after reading and responding to this thread I had some questions.

1). So if a patient of sound mind with their physician and family knowledge can make themselves DNR. How come when they aren't able to speak for themselves any longer because of a code etc how come family can then change their minds and go against this patient's wishes? I can see if family/DPOA chose the DNR to then change later... I'm just not sure WHY its ethically ok to go against their wishes?

2) What is it us nurses can do about this? Seriously there is enough of us we all see it day in and day out some patient who has a living will is DNR and family and docs go against it when a code happens even though patient made the decision themselves of sound mind. Surely there has to be SOMETHING we can do to better advocate for our patients.

[icyounurse, BSN, RN]

One word: Lawsuit. I'd love to see a DNR get well enough to sue a doc for NOT complying with his/her DNR.

It is a good idea to make your Medical POA someone you know will stick to your wishes no matter what. And it's probably good to make it someone who is not a family member. Now I just need to take my own advice and put my affairs in order, just in case. :icon_roll

A DNR surviving and then suing for having a DNR overturned? THAT would be fantastic to see:nurse:

[mama_d, BSN, RN]

1. Honestly, I don't think it's ethical that we do what we do sometimes in regards to changing code status.

2. I try very hard, when you can tell it's probably going to be time for the patient to go soon, to educate the family/POA as to what coding a patient actually entails. I have gotten in trouble for this before, but I see it as being a patient advocate first, family advocate second. I try to be as tactful as I can in bring the living will/advance directives and the patient's wishes to the attention of the family member(s) that are in disagreement, and then explain to them that running a code is not like it looks on TV. Regardless of what Dr. Green did on that one episode of ER, it is not likely that doing a full blown code on a 92 year old with multi-system organ failure and mets all over will be successful. Often, once they realize that CPR breaks ribs, a tube means that they will probably never breathe on their own again, and that coding the patient will just buy them a few more days of misery, they decide to go along with the patient's wishes. I'm lucky in that many of our docs are not afraid to address this issue with families as well.

[gonzo1, ASN, RN]

The important thing about having a DNR is that it makes a patients wishes known to one and all. I am a DNR within specific quidelines. I have discussed at length with family my feelings about this.

I think the beauty of a DNR makes it easier sometimes for the family to let go of the patient knowing that this is their wish. It helps take away the families guilt over having to make a decision.

Of course sometimes in the heat of the moment family panicks and there is nothing we can do.

It is helpful to remember that a DNR is a request and not a binding legal paper. I wish it was, but it is not.

[neurorn6]

Advance directives/DNR's are approached differently in different regions of this country. When I worked in the northeast, nurses were expected to obtain information on the DNR status/request of the patient immediately upon admission. We even had a patient advocate who came to the floor to assist pts and/or families on the decision. It was wonderful, our doctors respected and followed the patient's wishes. Education was the biggest key.

In the south and out west it as a different story. Especially in the south. Many times I would have a patient with an Advance Directive that was detailed in their wants and wishes. It drove me crazy when families would go against the patient's wishes. I actually had a nurse tell me that it was our responsibility to educate the family on what a DNR meant.

We actually had doctors write orders for a "Slow Code". I was trained to act as a patient advocate first and formost. The nurse I worked with didn't seem concerned as long as they followed what the "doctor" wanted.

My Living Will is very concise and to the point. I have made both my immediate and other family members aware of my wishes. I also told them that if they didn't follow them I'd be back to haunt they Ass!

[Ruby Vee, BSN]

i'm one of those family members who stepped in and overturned a dnar order.

i'm also an icu nurse -- over 30 years as a nurse, all but 5 of them in icu. i've seen a lot of family members overturn dnar orders for a variety of good (and not so good) reasons. "we don't want dad to die until after father's day." "if dad doesn't die until after his 65th birthday (three days from now) mom gets a bigger pension to live on for the rest of her life." "can you keep him going until his son gets here from iraq?" "my sister made him a dnar, and i don't want her to win."

dad woke up with chest pain one morning, thought he might be having an mi and went out to chop some wood to see what would happen. (he was having an mi.) he went to the icu, to the cath lab, got some stents and went back to the icu where a combination of emphysema and a panic attack made the staff approach my mother about intubation.

"no," she said. "he wouldn't want to be kept alive on machines." so they made him a dnar, put him on a 100% nrb and watched him become more and more confused, agitated and combative. during this time i was arranging a flight home from the opposite coast, flying across the country on the red-eye and being driven three hours from the airport to the hospital by dad's first cousin. when i got there, dad thought he was in prison. sats were dropping, and he was crazier than a bedbug.

mom explained the dnar order. i told her that with only one system failing, the ventilator would be a temporary thing, to allow his heart to rest for awhile -- not the same thing as "keeping him alive on machines." mom went off home to take a shower and change clothes, leaving me with my father. i talked to his nurses for awhile and made sure i had the full picture, then called his doctor and said "dad's sats are falling, he's increasingly confused and he's starting to have arrhythmias. i think it's time to intubate him." they did.

mom declared that my father would never forgive me for what i had done.

he was on the ventilator for 10 days, during which they diuresed him without checking a k+. predictably, he v tached. my mother and sister were all for letting him go then. i insisted they shock him. one shock -- that's all it took. and an explanation to the new grad nurse about the relationship of lasix and kcl, and k+ and ventricular tachycardia.

that was 10 years ago. dad forgave me for "keeping him alive on machines" and allowed as how he's had a good ten years that he wouldn't have had if i had not overturned his dnar. do i regret what i did? not in the least. i think my mother and sister were operating from ignorance, and (hopefully) not malice. would i do it again, now, ten years later? no way!

dad is ten years older. he's had a mostly good ten years, but he's starting to get frail now, and he's exhausted from caring for my mother whose alzheimer's is worsening. he doesn't have nearly as much to live for as he did ten years ago. i'm expecting him to fail sometime in the next year or two. he has his advance directive, and mom has hers. i wouldn't insist on keeping either of them alive. but i did what i did for a good (at least i think so) reason, and it turned out well.