Revived when there was a DNR/AND code status

[ambersky004]

There was this experience that I will never forget in my nursing career.

Patient N came back with Afib with RVR. She converted to SR during shift change. The night nurse said she had episodes of chest pain. From her report she said the Pt N was more anxious that night. Pt N told the attending doc she wanted to go home and if she die of a heart attack she is fine with it. Her code status was DNR/AND. The heart doc said she needs stress test or cardiac cath but she's been refusing the cath the last time she was in our unit. I told the hospitalist she has been talking about her dead sister this morning and she wanted to "visit her?" She was teary-eyed. She denies any chest pain except last night. She denies any depression or thoughts of suicide to the attending doc.

So the attending doc told her the plan is she can go home with an outpatient stress test. Her 3 Troponins where elevated but trending down. Her series EKGs shows she had a previous MI and afib. WHile I was discharging another patient and educating her family and answering there questions, I saw our CNA wheeling our crash cart. So I look where he is going and I saw staff in a room. It is weird I did not hear the rapid response called. So I went and saw the RT doing CPR and ambu bagging. Our on call doc was in room and I told him she is a DNR. I saw the V-fib on the heart monitor and the heart doc asked me a question and told him she came in with Afib RVR. He asked me who is the doc I told him the heart doc but forgot she was not on duty that day so he said to call her and asked what she wanted to do.

So I called her and she said she will be right there. When I came back pt's attending doc was in there now and told them and the on call heart doc she is a DNR but she was defibrillated anyway or they still defibrillate her. The patient woke up and was a little upset, she was telling me, "that was my time." Or maybe because she fell unconscious and she might still be in a fog. I feel so guilty. I felt like i missed something like putting the DNR armband. Maybe that would change the doc's and team members intervention since I was not there immediately in the room. I swear i did not hear the overhead call. The attending doc was telling me, she's going to be pissed. So I scratch my head and the heart doc laughed at me, I think 'coz he looked me in the face but i was so shooked up it happened so fast 'coz the attending doc just talked to her that time and I just rounded her. Lastly, the patient is alive and agreed to get a cardiac cath.

In regards to ethical issue and patient's wish during hospital stay, did we break her code status? Will there be an issue? I always thought that atleast try to revive the patient when there is a chance. And probably that was the heart doc's thinking but the attending doc was on the patient's side. Ughhhh. What should I do the next time i encounter this situation? I know the patient is well-knowledgeable of her condition and her risks.

[osceteacher]

That is not true.

Seems a bizarre thing if true, in the UK we do commonly have the issue where we commence CPR only to find out they weren't for CPR. We then stop. Because thats the patients wishes. What an absurd notion that you should continue.

[Nurse SMS, MSN, RN]

What is AND? I have never seen that abbreviation.

[Nurse SMS, MSN, RN]

Allow Natural Death. Guessed it for myself. Not an an acronym widely used in these parts.

[lifelearningrn, BSN, RN]

Shouldn't the DNR status be readily visible the moment she signs the documentation? Was that during your shift? If not, I don't see how you're anymore responsible for the start of the code than the admitting nurse, or the nurse that obtained the paperwork for not placing the bracelet on the patient. You were not in the room when the code started, you did not initiate the code. You notified them immediately when you were made aware they were doing CPR on your patient. The biggest mistake I see here is that you didn't document immediately. I've never heard of leaving without documenting..

[Crush]

​

Shouldn't the DNR status be readily visible the moment she signs the documentation? Was that during your shift? If not, I don't see how you're anymore responsible for the start of the code than the admitting nurse, or the nurse that obtained the paperwork for not placing the bracelet on the patient. You were not in the room when the code started, you did not initiate the code. You notified them immediately when you were made aware they were doing CPR on your patient. The biggest mistake I see here is that you didn't document immediately. I've never heard of leaving without documenting..

Not documented = not done. Do not add on an addendum without first consulting legal on how to do it first. But I am thinking too much time may have passed.

[GentheRN, ASN, RN]

Being a lowly nursing student admittedly knowing little about real life nursing, may I ask why you did not chart immediately on something so serious? I never considered leaving before charting as a possibility.

[Julius Seizure]

I highly recommend that you submit a report on this situation, using whatever incident reporting system that your hospital uses (they seem to have different names everywhere). Risk management needs to be made aware of this ASAP.

[guest940422]

Being a lowly nursing student admittedly knowing little about real life nursing, may I ask why you did not chart immediately on something so serious? I never considered leaving before charting as a possibility.

nursing school is going to do a great job of teaching you how to pass the NCLEX. The official answer is she didn't leave the room, use the bathroom, eat breakfast, administer medications, attend to her hypoglycemic patient, or reconnect a patient's circuit who's vent was alarming before she documented everything exactly the way it happened as if God himself had been in the room.

After you pass NCLEX the answer is: patient care always comes before documentation. If you can document in real time, DO IT, but odds are your assignment is rarely going to allow you to.

[guest940422]

Allow Natural Death. Guessed it for myself. Not an an acronym widely used in these parts.

I think we use AND more in peds because DNR has a stigma and scares the parents. They associate it with hospice and "giving up" and when someone's kid is dying they aren't much for a lesson on the misconceptions of hospice and DNRs

"Allow a Natural Death" sort of relieves them of the guilt they unfairly impose on themselves. I've read studies showing families are more likely to agree to an AND then a DNR in the same types of terminal cases. But I haven't heard of it being used much in the adult world.

[Here.I.Stand, BSN, RN]

nursing school is going to do a great job of teaching you how to pass the NCLEX. The official answer is she didn't leave the room, use the bathroom, eat breakfast, administer medications, attend to her hypoglycemic patient, or reconnect a patient's circuit who's vent was alarming before she documented everything exactly the way it happened as if God himself had been in the room.

After you pass NCLEX the answer is: patient care always comes before documentation. If you can document in real time, DO IT, but odds are your assignment is rarely going to allow you to.

I have knowingly left holes in my charting on days like those... But on something like this, if nothing else but to CYA? Should at least made a note that code was in progress and that she reminded the doc of the DNR.

[Crush]

There are times where we cannot chart right then immediately but on something so serious especially, I would have stayed over and not left without some good CYA charting.

[MunoRN, RN]

​

Not documented = not done. Do not add on an addendum without first consulting legal on how to do it first. But I am thinking too much time may have passed.

Any reasonable risk manager would have responded that they aren't going to "consult" you on how to write your note, that opens up a huge can of legal worms. They will remind you to chart accurately and appropriately, but not on what you should chart. And in general, there's not really a time limit on when something can be documented, having something documented late is always better then not at all.