Reamed for ordering an ethics consult

[WalkieTalkie]

This story is being posted with no identifying information to protect the innocent parties involved.

I am an ICU nurse. Last night, I was taking care of a patient in her late 70s who has been in the hospital for about a month now. She is septic and had a colectomy performed in early January due to c. diff colitis. Her abdomen remains partially open. She was only recently extubated and is not doing well. She has developed a secondary pneumonia, has terrible edema and wounds, is in great pain, can barely move, and is certainly suffering by all standards. The patient is confused at times, but also mouths and sometimes (when able) verbalizes that she does not wish to have this type of treatment.

The family approached me last night and told me that they have decided that they would like to make her a DNR/DNI. They told me that she never wanted this kind of treatment, and that since she is not getting better and the possibility of her recovering is slim, that they wish not to "code" her if her heart would stop beating and that they do not wish for her to be on the ventilator again.

As I would normally do in this type of situation, I paged the surgery team in charge and told them about the family's request. They were annoyed that I had even paged them. Even though they were in house, they did not come up to the room (this was around 2100). The chief resident spoke with one of the daughters but then refused to write a DNR/DNI order and did not talk to me again. The daughter was upset and nearly in tears and told me that she felt bad for asking. Apparently, the chief resident told her that there was "a chance" the patient could get better in "three months" and that she didn't need to be a DNR. I explained to the daughter, husband, and patient that there is nothing wrong with discussing this, and that if that is their wish, then they do have the right to enact it. I also explained that DNR/DNI does not mean we wouldn't treat her any differently, and we would still give her all the meds, abx, wound cares, etc, if that is what they would like for us to do. I told her that since the surgery team was not on the same page with them, that I would page the ethics consult person, which I did.

After initially speaking with the ethics consult, I was instructed to page the patient's attending. The chief resident had failed to even mention the DNR request to him. However, he basically reiterated to the family that the patient "might get better in three months" and that she "might" make it, doesn't need to be a DNR...yada yada. Meanwhile, the entire family is extremely upset as it has taken them a lot of time to make this tough decision, and they feel like they are not being listened to. I tried to speak with the attending after he got off the phone with the daughter, but he hung up the phone.

I then paged the ethics consult again to let her know what had happened. She agreed with me that not everyone was on the same page, and that there was definitely an ethical dilemma, and that she would come in to speak with the family in the morning. I charted that I had done all this (and with whom I had spoken to), mainly to cover my bases in case the patient would have coded during the night. The family thanked me for sticking up for them and even told one of the other nurses how appreciative they were for what I had done to help them in the situation.

Apparently, the chief resident must have read my electronic documentation this morning, because she called me and was infuriated that I had called ethics. She told me that it was "inappropriate" and that apparently "you don't understand what's going on with this patient." She asked me why I had called ethics and I told her that as a patient advocate, when a patient/family approaches me with the request to make their loved one a DNR/DNI, it is my duty to accept their wishes and that when not everyone is on the same page, a mediator is needed so that we can do what is best for the patient. She got even more upset and asked to speak with my charge nurse, who relayed the exact same information to her.

I can't believe I got chewed out for this! I printed out the policy and procedure regarding an ethics consult, and I followed it completely. I've previously had a decent relationship with this resident, and now I'm afraid what's going to happen when I go back to work and need to call her for something. :angryfire

Has anyone ever had this happen to them?

[WalkieTalkie, RN]

however the Nurse

1. shouldn't have paged the on call team for a DNAR, thisshould have been dealt with by the Medical practitioner in Charge of the patient's care at a sensible time (i.e. office hours the next day)

in volvgin Erthics dept is a good idea - this patient needs a 'best interests' meetings

In my opinion, this wasn't something that could wait. The patient was in the ICU for a reason. She was close to being reintubated during my shift. At bare minimum, the chief resident should have come up to speak with the family at this time (both she and the junior resident were in house, and were in house all night long). This initially happened around 2100, so it's not like I had to wake anyone up for it.

I guess I would have just expected common decency with regards to this woman's family, as it took them a lot of strength to decide that this was what was best for their mother. Had the chief and junior residents come upstairs, chatted with the family, and told me that they would discuss this with the attending, I would have been okay with that. However, they did not, and essentially told the daughter (on the phone) that they would not even consider making her mother a DNR.

I don't think they understand the difference between a DNR and withdrawing cares.

[rn/writer, RN]

however the Nurse

1. shouldn't have paged the on call team for a DNAR, thisshould have been dealt with by the Medical practitioner in Charge of the patient's care at a sensible time (i.e. office hours the next day)

In most places, anyone who is involved with a patient--doc, nurse, family member, even the patient herself (if capable) can initiate an ethics inquiry. And, if, as in this case, time is of the essence, this activation can take place whenever it needs to, not just during business hours.

If docs are the only ones able to start the ball rolling. what happens when the docs are the problem? In an ideal world, physicians would be able to let go when appropriate, but in the real world, that often goes against their programming. Highly self-aware people recognize their own internal limitations and call on the wisdom of specially trained others to make certain that personal and professional bias aren't getting in the way of ethical considerations. Unfortunately, that self-awareness is not as common as it should be. Then others need to step in and ask for those who are specifically trained to help determine the patient's best interest.

The second part--waiting for a sensible hour to call--is a nicety that should be observed when possible, but emergencies can't tell time. There have been cases where several members of an ethics committee have met via conference call in the middle of the night, made a decision, and contacted the hospital attorney to call a district attorney to ask for a warrant on behalf of a patient whose situation couldn't wait until office hours for a decision.

Each of these aspects of ethics committee initiation need to be just as they are.

[Rnandsoccermom]

You did the right thing, ethically, legally and morally. The surgeons and the hospital don't want her to die because it affects their statistics for mortality rate.

Interestingly, a friend had a similar situation in a SICU, it is the accepted practice at this facility NOT to make any of the open hearts DNR until 30 days after the surgery. They actually tell the nursing staff this. It makes me sick......

[lpnflorida]

I am so proud of you, as everyone appears to be who has read your post.

I am especially proud of the fact that though you feared possible repercussions you have continued to work with this same patient. Others might have gone under the radar by requesting to have a different patient. Not you, you not only advocated for her before you are being proactive by continuing to advocate for the best for her as evidenced by your finding no antibiotics ordered. Again someone else might have shrugged their shoulders and believe the discontinuation of all antibiotics was as it should be. Not you ,you recognized this had to be a mistake.You again did what needed to be done for your patient.

You are now my ideal of what it means to be a nurse.

[WalkieTalkie, RN]

Interestingly, a friend had a similar situation in a SICU, it is the accepted practice at this facility NOT to make any of the open hearts DNR until 30 days after the surgery. They actually tell the nursing staff this. It makes me sick......

Oh my! :omy: Considering how bad some of these patients get... I've seen my fair share of ones who we've kept alive forever, but usually it's at the family's request.

[northwestwind]

Culture, culture, culture! Sounds like a power struggle between the resident, you, and the attending. Hospitals often put out an ethics policy, but many residents are not fully aware of their role implementing the policy. Attendings may also not be fully aware of the written policy as it relates to how an RN may respond to a DNR decision when that decision has not yet been put in writing. Like many posters have commented, even if the attending felt the patient should not be a DNR, it is still up to you to keep the family in the loop, and do what you can to bridge the decision between the PATIENT, the patient's family, and the attending. A DNR on a chart, in writing, means that everyone, everyone, is on the same page. If the DNR is not there, and the family continues to request one, it is then time to quickly go to your manager, if he/she is there, or the nursing sup for sure, and make sure you define how you followed policy. This probably should have been done when this first occurred. In any event, your manager did not handle this appropriately. She/he should be your leader, your mentor, and your supporter, in situations where you do things right, and in situations where you may need to do things differently. This is a situation for the Medical Affairs Director's input, too. If your manager and resident both opposed your consulting an ethics person, why is there a policy in place at all? This sounds like a good learning case for everyone involved, and at some point you, your manager, the resident, the attending, the ethics officer, the compliance officer, the Chief Nursing Officer, and the attending need to sit down and go over this. Like today.

[WalkieTalkie, RN]

This sounds like a good learning case for everyone involved, and at some point you, your manager, the resident, the attending, the ethics officer, the compliance officer, the Chief Nursing Officer, and the attending need to sit down and go over this. Like today.

I told the charge nurse about the consult before doing it, and he agreed. My manager backed me 100%. I don't know if there will be a "sit down" or anything. I haven't seen the mentioned chief resident since this happened a couple of weeks ago, so I don't know if she will be treating me any differently or causing problems. However, my manager did say to tell her if this happened.

[nursemike, ASN, RN]

You did the right thing, ethically, legally and morally. The surgeons and the hospital don't want her to die because it affects their statistics for mortality rate.

Interestingly, a friend had a similar situation in a SICU, it is the accepted practice at this facility NOT to make any of the open hearts DNR until 30 days after the surgery. They actually tell the nursing staff this. It makes me sick......

My Dad went through some serious depression after his CABG. I wonder whether that might be typical enough to prompt the policy you describe. I don't think his wishes during the depressed phase would be the same as when at baseline. Might be a factor to consider, although I agree a hard-and-fast rule seems draconian. Still, I vaguely recall something from my OB rotation, that they don't ask about a tubal ligation immediately after delivery. I wonder if the rationale is something like that.

On the other hand, Dad's depression seemed to set in after discharge. While in the hospital, he didn't have the energy to be depressed. And by the time his sternum healed, he was mostly over it.

Regarding the OP, it occurs to me that if one is upset about an ethics consult, that ought to be a pretty strong clue that one is acting unethically. Add my kudos to the rest.

I'm curious whether the patient had appointed a medical power of attorney, or could have done so. Of course, if the patient is able to speak for herself, the MPOA is irrelevent (I wish more MPOAs understood that!) And if she wasn't able to speak (or write) for herself, there'd be no way for her to choose an MPOA. But if one were in place, it might have been a little harder for the docs to ignore. Maybe.

I had a very young pt (18 or 20, thereabouts) with DNR orders, awhile back. Made me cringe a little, when I saw them. Then I thought about, a.)the pt was unlikely to code during that admission, and b.)what a code is really like. The pt's chronic condition did make the possibility of a code at some point in the future rather more likely than for others that age, but stopping and thinking it through did make it easier to accept.

[WalkieTalkie, RN]

I'm curious whether the patient had appointed a medical power of attorney, or could have done so. Of course, if the patient is able to speak for herself, the MPOA is irrelevent (I wish more MPOAs understood that!) And if she wasn't able to speak (or write) for herself, there'd be no way for her to choose an MPOA. But if one were in place, it might have been a little harder for the docs to ignore. Maybe.

Yeah, she actually had a living will/advanced directives form which was not on the chart. The husband had the paperwork but was scared to bring it in initially. The daughters faxed it over the following morning. In it it states that the patient doesn't want life supportive measures if she is terminal or in a vegetative state (not terminal at this point, but certainly her chances of making out of the hospital are slim to none). It also said that the husband can make decisions when she is unable (she isn't capable due to confusion following a prolonged hypotensive period, infection, ICU psychosis, etc). When the patient was lucid, she kept telling the family that she didn't want to e treated any more. Last I checked, the patient had moved to the floor, but she's in a different tower, so I'm not sure how she's doing.

[MAISY, RN-ER, BSN, RN]

Honestly I believe everyone has the right to do what they want and make their own decisions. I have already mentioned in another thread how I'd head to Vegas if I found out I was terminal and want no part of existing in an ICU or anywhere else. Out to the desert, a little dehydration on a sunny Mesa....works for me.

My kids said " I think you are depressed"....so much for family input. Proving my point that you need to be clear with physicians, family, friends, anyone who will listen. Because of a sudden you are depressed or not thinking right when you make these decisions under duress.

No one can understand until you are the patient, in pain, chronically suffering or whatever else. I think the OP should get a standing ovation:yeah:and anyone who had a problem at her hospital get REEDUCATED!