witnessing a DNR - page 2

We had a patient who was actively dying. The MD spoke with the family and they were deciding whether or not to make this patient a DNR. I went into the patient's room with the primary RN to see the... Read More

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    I am really confused by the situation (which is probably just my mind, but oh well...). Did the MD have the talk with the family well before the family decided to make the pt a DNR and now you were stuck in the position of trying to make them a DNR when there was no doctor present? Based on the the OP it sounds like the policy is that the pt/POA can make the DNR decision, tell a nurse who finds 2 random witnesses and that is all it takes. Am totally missing it. It just all seems weird to me....again, that might just be my misinterpreting it.

    Also, as people have mentioned, this sounds like a HIPAA disaster! Pull a stranger into a room to witness a pt telling them they are a DNR?? Suppose you didn't realize it in advance, but suppose that witness has something to gain by knowing that the pt is going to die? The privacy issues there just blow my mind.
    turnforthenurseRN likes this.

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    It can take more than "just" a physician order. Some facilities want it signed by a second MD. At my last facility, getting a telephone DNR order required a witness, so we'd put the doc on speaker and two nurses would sign the telephone order. But there is absolutely no situation in which it is appropriate in a hospital to get a random visitor to sign something. This is just plain weird. I'd also double check this is really the policy and if it is, take it to risk management.
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    Quote from wooh
    This is just plain weird.
    I know I used the word weird also. I would also add creepy and illegal.
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    this seems like a HIPAA violation to me. I think your facility needs to talk to an attorney about what is really required in such an incident. Pulling people out of rooms in the middle of the night for ANY reason other than meeting their own loved one's needs is ridiculous.
    JDZ344 likes this.
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    Working in Risk Mgmt, I think you need to have your policy revisted. This is not ok in any US hospital in America. If it is, this is a crime! I would contact your administration or risk department for guidance. I think there is some ignorance on someone's part, just not sure who.

    Quote from turnforthenurseRN
    We had a patient who was actively dying. The MD spoke with the family and they were deciding whether or not to make this patient a DNR. I went into the patient's room with the primary RN to see the patient; their eyes were glazed over and they were agonal breathing. The patient's extremities were warm but after some time the primary RN & I noticed that they were starting to cool down and the patient started turning pale.

    The decision was made to make this patient a DNR. Now we needed witnesses; we had some family members on the unit. I had a patient with a family member in the room, so i decided to ask them. The family member was already sort of awake and I politely explained to them that we have a patient just down the hall and there was a decision to make them a DNR but we needed two witnesses. The witnesses had to be unrelated to the patient/family members and they could not be employees of the hospital.

    I told the family member they weren't obligated to be a witness if they didn't want to. The family member said to me, "Oh, but I was sleeping so good, and I don't think I can make it to the room...where is it?" "Just across the hall." "Oh ok, but I don't think I could make it...." and I reminded them they didn't have to be a witness if they didn't want to, and it sounded like they didn't want to do it. Then they started talking about all sorts of other random things before finally (reluctantly) agreeing to witness.

    The primary RN was standing in the hall trying to usher me out and I was trying to speed things along...I really wanted to just tell this family member, "the patient is ACTIVELY DYING and if we don't get this DNR signed SOON, we may have a full code on our hands and that would be against the wishes of the family." I then realized that could be a HIPAA violation, so I kept my mouth shut.

    We finally arrived to the outside of the patient's room and almost immediately the family member said, "Oh you don't need me" and started walking back, but I told them we needed TWO witnesses, unless of course now they are not agreeing to witness. They reluctantly stayed, signed the paper and then I escorted them back to their room.

    It was not like I was trying to twist this family member's arm into witnessing this DNR, but it sure felt like it. In the past I have asked visitors to witness a DNR and they have all immediately agreed to it. I don't know, I was just annoyed by it and I wanted to get this off my chest, I guess! Sorry it was long. Thanks for reading.
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    Trust me, I am NOT okay with the policy. I agree, there are a lot of issues with it and I think it is wrong, but for whatever reason no one has ever said anything about it. Perhaps I can take the issue at hand myself to risk management or whoever.

    The "witnesses" did not go into the patient's room.
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    Quote from turnforthenurseRN
    The "witnesses" did not go into the patient's room.
    How would they witness a person making themselves a DNR without going into the room? Even if the family makes a loved on DNR and the witness speaks to them in the hall, the witness still needs to at least sign a piece of paper with the pt's name on it. Anyway, go for making a change. Find the written policy and take it to some one. Don't be militant in you opposition to it. Go to risk management or legal and say "I have some concerns about this policy. One of my biggest concerns is that it violates HIPAA, and I am worried if someone filed a HIPPA violation against the hospital based on this policy."
    pgotm and wooh like this.
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    Agreed. I also wonder how having a "stranger" sign a document that I am assuming is stamped/stickered or some how labeled with the pt's name, dob, age--or even involving them in witnessing--is not in violation of HIPPA law?
    Very much worth further discussion/evaluation.
    At every facility I have ever worked, it has always been a family+MD conversation= MD order.
    Maybe you could provoke this very much needed second look at your facilities policy somehow?
    Inquire with the QI folks or even ethics committee?
    Just thinking off the top of my head...
    pgotm likes this.
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    I know it's been said but this policy is weird. I wouldn't feel comfortable as a nurse or visitor/witness in this situation. At my hospital it is a written document signed by the attending physician, until it is signed by the ATTENDING it is not valid, no random strangers needed. I would ask around, see if this is indeed policy, maybe it can be changed since it could come back to hurt the hospital.
    pgotm likes this.
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    I wouldn't do this again. This sounds bizarre. Most doctors I have worked with talked to the family at length and then wrote the DNR with progress notes detailing the conversation with the family. Some docs would prefer to have a nurse in the room as a witness to the discussion with the patient or family, but that's it. I have witnessed countless DNR discussions and orders and never remember a problem and have never even heard of anything like this. I have seen more problems with running a code when the patient was supposed to be a DNR. Now, Power of Attorney, that's a different story.
    pgotm likes this.

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