witnessing a DNR

[turnforthenurse]

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.

[Caffeine_IV]

I've never heard of such. I think I would much rather code a patient then follow such a policy. It makes no sense having a random person sign a document about code status of someone they do not know.

[smurfynursey]

something is fishy about this story...Don't know if its the policy, or the details, or the "story" in general...

[turnforthenurse, MSN, NP]

The story is told exactly as it happened. No details were omitted, as much as some would like to think, it seems :/

Thanks for everyone's input.

[Pepper The Cat, BSN, RN]

I think it is asking an awful lot to ask a visitor to help decide if someone else should live or die.

That might why the person you asked was "dilly-dallying". I think they really did not want to do it, but was afraid to say No because of possible repercussions to their loved one. That is why I said I thought you were twisting their arms.

You and I both know they were just witnessing the decision, but those not familiar with DNRs might feel different.

No matter what, this is a policy that needs to be updated!

[lrobinson5]

I agree with the others about HIPAA. I don't see how it is acceptable for the policy to demand people to witness that really have no business dealing with patient information.

[*LadyJane*]

Where I have worked, only two rn's have signed. I suspect this story.

[Mommy&RN, BSN, RN]

If for some reason the MD needs to make code status via phone, the order must be given to 2 RNs. No random people involved.

[NRSKarenRN, BSN, RN]

Missouri is the only state that requires two witnesses for DNR orders.

Forty-nine states currently permit the next of kin to make medical decisions of incapacitated relatives, the exception being Missouri. Missouri has a Living Will Statute that requires two witnesses to any signed advanced directive that results in a DNR/DNI code status in the hospital.

en.wikipedia.org/wiki/Do_not_resuscitate

Excellent info on how to initiate discussions:

DNR: DO NOT (ATTEMPT) RESUSCITATION - Missouri ACP

Time to Resuscitate the Code Blue Discussion[

[alotusforyou]

I'm not a nurse (yet), but I would feel really awkward in this situation as a visitor of a patient. I would be dilly dallying too, trying to figure out what was going on and why I would need to be involved in a stranger's care. At the same time, if I really wasn't aware of how these things work, I would feel guilty just saying no. I would want to help, but it wouldn't feel kosher at the same time. You know?

And if hospital staff woke me up for something not related to the patient I knew, that hospital would be getting some bad reviews for sure. :)

[Esme12, ASN, BSN, RN]

The story is told exactly as it happened. No details were omitted, as much as some would like to think, it seems :/

Thanks for everyone's input.

It is just that you can't ask complete strangers to witness another patients document. I have seen hospitals do some bizarre things in my day but if they really do this.....it's right up there in the top 10!

[TX.RN.Shannon]

In my institution, an Advanced Directive (being written by a competent, appropriate PATIENT) is witnessed by 2 people when signed. Basically, the witnesses are signing only that they saw the document being signed. Usually it is done by the hospital 'Pink Ladies' volunteers. Most often, there isn't a problem with anyone--patient, family, witness--feeling akward or put out.

In a couple of isolated incidents, we have asked other visitors to be a witness. I work nights, so there's a lot of improvising going on.

I had a patient who insisted on writing her Directive at 0200 in the morning. There was no Social Services or Pastoral Care available to help her, so the Charge Nurse (Me) had to.

After filling out her Advanced Directive and Medical Power of Attorney, with her family's help, I rounded up two witnesses. I explained to the witnesses that I just needed them to watch the patient sign a document (nothing else disclosed to them) and sign their name as a witness that they saw the patient sign said document. Took about a minute, then all was done. No problems from patient, family, witnesses, or staff.

But in a situation of an emergent DNR like described above, involving strangers doesn't seem appropriate. It seems like the 'witnesses' in that situation would definitely make it an uncomfortable HIPAA violation.

[amygarside]

That is a strange situation indeed!