DNR questions... Family vs Patient wishes.

Nurses General Nursing

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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.

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Specializes in Emergency.

Well to answer 1) the pt is now dying and reality has set in. Its easy to make yourself or a loved one a DNR when things are good but its an entirely different situation to act on it.

Rj

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Yes but if patient requested it.. why can we go against their wishes. Especially when 90 yr old and comorbitities. Its one thing if PT changes their minds.. but I'm not sure it seems ethical for pts to have their wishes over riden to just end up in hospital for weeks on end to die anyways or come out of whatever is going on incapacitated.

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Specializes in LTC,Hospice/palliative care,acute care.
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.

There is nothing we can do about it-the docs don't have the balls to stand up to these selfish family members- afraid of getting sued.Our society is so "right to life" across the board that even in this type of situation our hands are tied.Read Pennsylvania's act 169-it's a real hoot.We are moving away from having the right to choose to die with dignity.THe issue of advance directives and health care representatives is a very complicated one-we can encourage our patients and their loved ones to document their wishes and encourage them to honor those wishes until we turn blue but we are always going to see this happen until advance directive are determined to be a legally binding document.Those documents are open to interpretation-and docs don't hesitate to tweak the scenario to give the s/o's what they want.

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Specializes in Acute Care, Rehab, Palliative.

It may depend on where you are. Where i work if a pt has made themselves a DNR and then become incapacitated the POA cannot change the code status.

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Specializes in Trauma ICU, Surgical ICU, Medical ICU.

Basically the law is the law. We have ethics rounds every few months in our ICU for patients such as these,we always have at least one or 2 in our unit at all times it seems. Now, MDs CAN stop in some states. Per NC law if you have 2 MDs state that what we are doing is medically futile then you can stop and have no reprocussions, but they can still TRY to sue you. That's the problem. The MD is out money and time to help others for some stupid lawsuit which he will win.

The best thing you can do as a nurse plan family meetings as often as possible with the MD (preferably the attending), discuss what a code entails, have a plan of who will be present, let them know they can stop whenever they want. Discuss with other nurses how we will educate this family and reinforce what other nurses have said. Basically most of these family members WILL treat you like crap and hold on to any glimmer of hope, pin one nurse against the other, so its best not to sugarcoat and tell the whole truth about the pt's condition. Let them know that the code WILL break their frail loved one's ribs, we dont know if they will feel any pain. Explain all the rules (family in the room or not, children not allowed, etc) Explain that if they become a problem they will be asked to leave. Educate Educate EDUCATE!!! Make the experience as tolerable for everyone as possible. Be sympathetic even though you want to smack these people, hard. You don't want to get into any other issues with family members or get in trouble with management.

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Specializes in MICU, SICU, PACU, Travel nursing.

Agree with what others are saying. Families CAN in most areas of this country overturn DNRs all the time, and they DO overtunr these DNRs all the time. I think its very unfortunate as the families motives are not always so pure (they may be receiving a check from the state for example, and it may the families only source of income and if the patient dies they wont get the check for example). Often families are just going through the stages of grief and are angry or in denial, and sometimes they are just plain selfish, unrealistic or uneducated about the natural dying process.

But whatever the reasons the family has to overturn that DNR, its very rare to see a doctor go against their wishes. Is a dying cancer patient who is incapacitated going to sue the doctor for overturing it?? Probably not.

Is an angry in denial family member going to sue a doctor for not honoring their wishes??

Maybe.

Doctors are protecting themselves, and no I dont agree with it, but I can see where they are coming from. We live in a very sue-friendly culture and the courts almost always side with the right to live, versus the right to die.

Its very sad indeed, but a stark reality here in the ICU.

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I think this is a legal issue.

When you are of sound mind YOU DECIDE your legal wishes, such as DNR.

When you become unable to make decisions, whoever is the POA, or if no POA a family member can legally make your decisions. This of course means overturning your DNR. It's purely legal.

This is why they tell you to have a third party like a lawyer as your health POA or a friend NOT a family member. If the POA is a friend legally a family member CANNOT change the DNR status.

I think the main reason doctors and nurses go along with the families is that most people whose wishes are ignored are never able to sue. The families however can so the industry has taken the less ethical but mor financially sound path...

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Specializes in Acute Mental Health.

I asked the same question when I was new to ICU and was told that when families take over and insist on bagging the dnr, the doc's go along with it because they are covering their own butts.

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Specializes in dialysis (mostly) some L&D, Rehab/LTC.
Agree with what others are saying. Families CAN in most areas of this country overturn DNRs all the time, and they DO overtunr these DNRs all the time. I think its very unfortunate as the families motives are not always so pure (they may be receiving a check from the state for example, and it may the families only source of income and if the patient dies they wont get the check for example). /quote]

You are so right...sometimes...it's all about the almighty $$$$!:crying2:

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Specializes in Med Surg, Tele, PH, CM.

As a case manager, I try to get all my patients set up with Advanced Directives. I always make several points. You can change your mind, and rescind the order. You need to discuss any decision you make with your family and make sure they will respect your wishes. You need to choose a POA who will stand up to dissention in the ranks. THen I counsel my patients to qualify their decisions with notes so there will be no question about their wishes. I had one elderly patient write on her form " Don't keep me alive if it means I will not be able totake care of myself - I live with my daughter now, and the only thing she does for me is to allow me to babysit for her brats after school. She takes my pension check and Social Security and complains when I ask her to buy me something. Of course she will want to keep me alive, I am a paycheck for her." She named her nephew who is a nurse her POA. Needless to say, I made sure a copy was placed in her PCP's record and given to the nephew. I love this lady's spirit, I hope she lives forever, but when it is time for her to go, I will definatly advocate to make sure her wishes are carried out.

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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

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