Advanced directives

[LEM.LPN]

Hello. I am working in a LTC. One night shift, a resident had a very bad fall. He hit his head and had a grand Mal seizure. After placing him on his side i noticed that there was a cut wound on his parietal area and blood streaks was on the floor. After the seizure he loss consciousness and is unresponsive to painful stimuli plus having DOB.. His advanced directives says that everything is about comfort care. I did called my supervisor that I sent the resident to the hospital. Was my decision wrong? Since his advance directives says comfort measures.?

[PixieRN1]

I think you did the right thing. You didn't initiate a code (which would have felt fuzzy I imagine...was he also a DNR?). I can't see how it would have been remotely okay or permitted to plop him back in the bed and potentially let him die...all in the name of comfort measures on the back of a mere advanced directive...that's an MD and POA call unless a legal DNR is in place.

This isn't dying the death he may have expected from whatever was terminal. This is a sentinel event in the works.

Sending him to the hospital allows his family or POA to make the call about what is done, in lines with his written and previously spoken wishes, moving forward. And while an advance directive is great, it's not a DNR and you had no ability to tell if the need for rescusitation was coming around the bend if he didn't have a DNR.

And I don't know about you, but I'd rather let the very skilled, wise, and seasoned folks in the ER decide when/if he needed rescuscitation. They deal with accidents and trauma all the live long day and they are the experts. I congratulate you on making the call to let them suss it all out.

LTCs just don't deal often with death from an unexpected, traumatic injury in the face of directives and DNRs in place for other conditions. Expected deaths? Absolutely! Call 911, get his chart, directives, and legal papers ready STAT for EMS, be available to answer any questions that the ER might call you for about his medical history, contact the patient's emergency contact like yesterday...I really think that you did good.

You see, I have an advanced directive that says comfort care only in the face of a terminal illness. But I don't have a DNR. And if I fell and had a big head injury, even towards the end of life, first responders (which you sort of were) can't decide that my injury is in fact fatal and not to be recovered from with reasonable measures. Leave that to the trauma team.

I have a hard time believing that you could defend NOT treating him by sending him to a hospital in a court of law, particularly since he basically fell on his head under medical supervision.

He wasn't coding. You couldn't diagnosis his prognosis lying on the floor in a pool of blood. Only the hospital MDs can do that. Deep breath, I believe you did the right thing and in your shoes, as you have explained it, I would have done the same thing by calling EMS and sending him on.

Even if he had a DNR, you didn't initiate rescuscitation. You did the right thing, at least in my book.

[mrsboots87]

Just think about it this way. DNR and comfort measures only does NOT mean do not treat a trauma. It nearly means not to extend life when actively dying. Now, if his living will states that under no circumstances is he to be sent to ER that would be different and his choice. It would still warrant a call to the POA and the doctor to confirm not sending. POA may wish to override the living will and have the resident sent. It's a tough call to make, but there would be little no no circumstances in which I would personally decide not to send a resident out in this scenario without doctor and POA consult. You did the right thing.