Advance Directives Ignored

  1. A short while ago, I had a pt who was going to surgery to have a leg amputated due to complications of diabetes. She had an advance directive and we discussed her fears concerning the surgery. In a nutshell, she was afraid something would happen during surgery and she would be a vegetable (her word) since that's what happened to her husband.

    She came thru surgery fine, went to a local SNF for recovery/PT/strengthening. 2 weeks later, she returned to ICU in respiratory failure, unable to speak for herself. Her sister came in, as closest living relative, and completed a "Withdrawal" which stated she understood the condition was terminal and she made her comfort measures only. Didn't even want blood draws. From my discussion with the pt. herself prior to her surgery, I knew that was what she wanted. Pt. pulled thru enough to be sent back to SNF on "comfort measures only." SNF screwed up paperwork and called EMS to send her back to hospital for blood sugar over 800.

    Here's where it gets hinky. The primary MD immediately set about doing "everything" for this woman in a coma. I pulled the paperwork from her previous admission and questioned whether we were acting according to the pt.'s and family's wishes. The MD told me that the withholding was valid only for the diagnosis of "respiratory failure" and thus didn't have anything to do with the diagnosis of DM.

    Took it to the supervisor, called the sister and hooked the sister up with the MD to discuss what was to be done. The MD told the sister that if she filled out another withholding, the pt would be sent back to the SNF that day. Since the sister thought she was getting better care at the hospital, she didn't keep the withholding. We poked and prodded that woman for another 3 days before she finally was able to die, never having opened her eyes, said a word, moved a muscle under her own power.

    Oh yeah, she had supplemental insurance to her medicare, in case that's important.

    So, what do you all think? Was the MD in the right? How binding do you find advance directives to be? What would you have done differently?
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  2. 11 Comments

  3. by   freddy
    I would have done what you did. Since you had previously discussed advanced directives w/ this patient before, I also would have thought the patient's wishes would be the same. This is the first I've heard of advanced directives on a "by diagnosis" basis. Not sure about the legalities of that, I'm sure it varies by state.

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  4. by   moia
    It has become the practice here where I work that a DNR with comfort measures is only valid for the hospitalization when the order was made.

    That is why it is so important to have a legally binding document that states what you want done before you get sick.
    If your patient had entered hospital with documentation ready she would have been left alone with comfort measures but all she had was an order from a previous hospitalization from a completely different diagnosis.

    The doc unfortunately was right...the family member who knew her wishes and had already agreed to DNR.... well she sucks...all she needed to say was the previous order for DNR was still appropriate and should be enforced.

    The patient should have done the paperwork in the first place but that family member really let her down.
    At least she was not conscious and suffering...I have had families prolong death and they knew the patient was suffering...thats a horrible way to treat someone you say you love....I always say if that is love I would prefer hate.
  5. by   chris_at_lucas_RN
    I've never heard of Advance Directives being diagnosis specific. I think the doc was wrong.

    Applause for the OP--that took guts and demonstrates the kind of nurse you are--willing to do what your patient needs.

    As for that MD, it reminds me of that tired old saw: what do they call the guy with the lowest passing grades in med school? Doctor.
  6. by   Celia M
    Unfortunately I think the Doc was probably right as the "witholding " had been signed by the sister. Had the patient had an advanced directive signed by her then the Doc would have had to have followed that . It's probably something that should have been completed in the hospital or at the SNF following the patients recovery from the respiratory failure. In the end the sister failed the patient by going aginst her wishes but without an advanced directive the Doc had to follow the siaters wishes. I think everyone should have an advanced directive.
  7. by   moia
    An advanced directive and a DNR order are quite different.
    Think of it this way...you are in terrible car accident..you have terrible injuries and have been coded several times...your family decides that enough is enough and they agree to a DNR.
    You to the shock of everyone survive and go to rehab where you get pneumonia...so are you still a DNR? ofcourse not...the DNR was for a certain set of circumstances..the doc can't rely on a DNR made when it was likely due to your diagnosis you were going to die.
    The patient survived the diagnosis where the DNR was instituted...those circumstances no longer exist.
    The doc must make a new diagnosis and in good conscience discuss with the family if the previous DNR is appropriate.
  8. by   sixes
    Comfort measures at our LTC means they don't get sent to hospital only comfort measures this is Advance Directive #1

    Advance directive #2
    Comfort measures with the addition of antibiotics

    Advance Directive #3
    To hospital for assessment and treatment No CPR no Intensive Care Unit

    We follow this strictly we always discuss each new finding with the family or resident as everyone has the right to change their mind

    Hat s off to those who advocate on behave of their clients who can't do this for themselves anymore
  9. by   suzanne4
    advanced directives are legally binding and state what the person wants done and does not want done. this patient had a set of papers.

    simple and easy, the doctor did not follow the patient's wishes. patient was already in a coma as previously stated by the poster, how would treating a blood sugar of 800 make any difference in her neurological status at this point. if her wishes were no measures and she was in a ltc, then those wishes should have been followed. but if the patient was on comfort measures only, why was she getting her blood sugar checked. that is really where the whole problem started. blood sugars are not comfort measures. who ordered those? if they weren't ordered then they never would have had an elevated sugar to chase. :angryfire
  10. by   susanmary
    :wink2:
    Last edit by susanmary on Jan 14, '05
  11. by   critcarenurse16
    We have a problem at my facility with docs ignoring DNR's and advanced directives. Twice we have intubated a DNR because doc says "it's unethical for me to let this pt die". I told one doc he can get the cart himself, do it himself-I refused to assist-period!. He got another nurse-one he could bully into helping.And she did. I immediately contacted risk management. This issue is still pending in the ethics committee- but will probably go nowhere since the doc is chief.:angryfire :angryfire :angryfire
    (God called- he wants his job back)
  12. by   vibe9
    Quote from critcarenurse16
    We have a problem at my facility with docs ignoring DNR's and advanced directives. Twice we have intubated a DNR because doc says "it's unethical for me to let this pt die". I told one doc he can get the cart himself, do it himself-I refused to assist-period!. He got another nurse-one he could bully into helping.And she did. I immediately contacted risk management. This issue is still pending in the ethics committee- but will probably go nowhere since the doc is chief.:angryfire :angryfire :angryfire
    (God called- he wants his job back)
    YOU GO!!! I HOPE YOU CAN HEAR ME APPLAUDING FROM HERE!!!!!
  13. by   vibe9
    Quote from TracyRN
    A short while ago, I had a pt who was going to surgery to have a leg amputated due to complications of diabetes. She had an advance directive and we discussed her fears concerning the surgery. In a nutshell, she was afraid something would happen during surgery and she would be a vegetable (her word) since that's what happened to her husband.

    She came thru surgery fine, went to a local SNF for recovery/PT/strengthening. 2 weeks later, she returned to ICU in respiratory failure, unable to speak for herself. Her sister came in, as closest living relative, and completed a "Withdrawal" which stated she understood the condition was terminal and she made her comfort measures only. Didn't even want blood draws. From my discussion with the pt. herself prior to her surgery, I knew that was what she wanted. Pt. pulled thru enough to be sent back to SNF on "comfort measures only." SNF screwed up paperwork and called EMS to send her back to hospital for blood sugar over 800.

    Here's where it gets hinky. The primary MD immediately set about doing "everything" for this woman in a coma. I pulled the paperwork from her previous admission and questioned whether we were acting according to the pt.'s and family's wishes. The MD told me that the withholding was valid only for the diagnosis of "respiratory failure" and thus didn't have anything to do with the diagnosis of DM.

    Took it to the supervisor, called the sister and hooked the sister up with the MD to discuss what was to be done. The MD told the sister that if she filled out another withholding, the pt would be sent back to the SNF that day. Since the sister thought she was getting better care at the hospital, she didn't keep the withholding. We poked and prodded that woman for another 3 days before she finally was able to die, never having opened her eyes, said a word, moved a muscle under her own power.

    Oh yeah, she had supplemental insurance to her medicare, in case that's important.

    So, what do you all think? Was the MD in the right? How binding do you find advance directives to be? What would you have done differently?
    I HAVE READ ALL THE POST AND EVEYONE MAKES A VALID POINT.
    WHY WAS HER SUGAR TAKEN??
    DID SHE HAVE A LIVING WILL OR WAS SHE JUST A DNR DURING THE HOSPITALIZATION.
    THE SNF SHOULD HAVE HAD A DNR ORDER THAT COULD HAVE BEEN VERIFIED ONCE SHE GOT THERE THEN THAT MIGHT WOULD HAVE HELPED.

    THAT IS A STICKY LEGAL SITUATION BUT I THINK YOU DID THE RIGHT THING AND THAT WAS LIVE AND PRACTICE BY YOUR CONCIOUS. IT SHOWS YOU CARE AND THAT IS A GREAT JOB DONE ON ANY DAY!!!

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