can the family reverse a patient's decision?

[DNM-BSN]

My question is, how can the family come in and reverse a decision that the patient made when he was alert and oriented?

Here's the story....

I'm an ER nurse and I took care of this patient when he first was brought to the ED via rescue c/o SOB. He was, of course, admitted to hospital. About a month later, by coincidence, I was working when the hospice floor called the ER and wanted to transfer a patient to the ED because he rescinded his hospice care and he ended up being my patient again.

The patient - late 80s, A&Ox3 male had end stage lung cancer, which according to his doctor was quite aggressive. Like I said, he was my patient before and he was totally with it and capable of making his own decisions. After being admitted to hospital, he signs himself into hospice after a discussion with his PMD and signs a DNR.

After being in hospice for approx a month, he became my patient again, except this time he was not responsive at all, not even to pain. Also, this time around several of his relatives were there and were accusing the hospice nurses of being inhumane. Of course, I called the hospice unit and asked them what was going on with this patient. She said that over the month, the patient was starting to decline. He was eating/drink less and then eventually not all, he started to become less and less responsive. The relatives wanted IV fluids to be started since he wasn't drinking anymore. She said the relatives were doing this all afternoon when finally one of the them says that she wants him transferred off the hospice unit. They called the PMD, but he said he couldn't do anything because the patient signed himself into hospice when he was alert and oriented, although he is not anymore. This is when we get a call in the ED that the patient rescinded his hospice care and is being transfered to ED so he can be admitted to regular room, as a FULL CODE!

I asked how this patient was able to sign himself out if he isn't responsive, he didn't even flinch when I put an IV in his arm. She said it was the family's decision and they "forced" him to sign the paper. So, in the ED we drew blood, started him on IV fluids and treated him as a full code.

Any input to help me understand how this is allowed would be appreciated because this really upsets me. I was under the impression that we are supposed to honor the patient's wishes regardless of what the family wants. I feel like my hands are tied on this one since no one involved seems to think any differently.

Thanks.

[WalkieTalkie, RN]

How sad

I've seen this happen at my hospital too...

[caroladybelle, BSN, RN]

This happens quite often, unfortunately. MDs are more afraid of being sued by the live family than the no longer cognizant pt.

I would hope that the Health care legislation would have put more "teeth" in the recognition of living wills - since the pt would have had a very educated, well thought out discussion with the MD ....that there might be less reversals by family. But that is shot down by people that insistant that such discussions would lead to "death panels" and that this should be kept "in the family", who often have little knowledge of medicine and may make these decisions at a very emotional time, without all necessary facts.

[JBudd, MSN]

You can take this to your hospital ethics committee, but it may be too late.

There are also omsbudsmen through many states, through whatever agency oversees elder abuse complaints.

Its sad when families can't let go.

[elkpark]

I've seen this happen, too. It's sad, but the hospitals and physicians will "choke" and go with what the family wants -- they are more afraid of being sued by the family for not doing enough than they are of being sued by the client (who will probably soon be dead either way) for doing too much ...

Unfortunately, in my experience (observation), living wills and other advanced directives are meaningless unless the family agrees with the plan -- I think we should warn people of this up front. People also need to be aware that, with a DPOA, once it has been activated and the other person is making decisions for you, that person is under no obligation to do what you want done. The POA can come in and undo the arrangements (advanced directives) you've already set up once you're no longer able to direct your care yourself.

[catshowlady]

You can take this to your hospital ethics committee, but it may be too late.

There are also omsbudsmen through many states, through whatever agency oversees elder abuse complaints.

Its sad when families can't let go.

:yeahthat:

[Straydandelion]

I have seen this happen also, it ultimately boils down to who is going to sue I think. On a side note, I don't see why a hospice patient couldn't have had an IV if it would make the family feel a little better and keep him in hospice. I don't think it would have affected the outcome and would have made the relatives who I am sure are frustrated with the situation, possibly more accepting.

[diane227, LPN, RN]

Yes they can. Unless the patient has a specific person appointed as his/ her POA for health care. Then only that person can make changes in those decisions. If the POA for health care wants to make changes, they have the right to do so.

If the patient does not have a designated POA for health care then you have to revert back to your state law regarding who is allowed to consent for the patient. The law will outline who is able to give consent and in what order and you have to follow that law in regard to decision making. If you feel that the best interest of the patient is not being taken into consideration, you can make a referral to APS and have them evaluate the situation and request a temporary guardian for the patient, someone outside the family. Your social worker and risk manager can help you with those things.

[rngolfer53]

What happens fairly often is a relative who's not been involved with the Pt now comes into the picture and wants to run things....................no matter what the Pt may actually want.

If the DPOA is not emotionally and mentally strong enough--and they are often exhausted and not functioning at their usual level--he/she will get browbeaten into sending the Pt to the ED, full code, etc.

One can only hope the Pt comes back to haunt the busybody.

About the only way to protect yourself from this is to pick a DPOA who is trustworthy, mentally tough, and is removed enough to be able to remain true to your wishes.........I think it's often a mistake to have a spouse or other close person as a DPOA.

[florianslove]

Just today we had a 96 year old whose family wanted hospice, "I don't want mom going to the hospital for blood tranfusions", hospice consult, yes we're going to hospice, now say, mom's not the same. Our medical director, who seems afraid of his own shadow, ordered stat CBC's and other blood tests. In the mean time this lady had a severe hypotensive crisis, BP 70/40, unresponsive, O2 sat of 84% on oxygen. Bottom line is we sent her out 911, this poor lady will most likely be intubated, have a blood transfusion and a myriad of other tests.

The daughters' can't let go. The patient is ready to let nature take it's course. However, our MD is afraid of his own shadow and will do everything possible to cover his **s. All we can do is wait and see what happens to this poor lady.

Roxann

[SharonH, RN]

Here are my observations:

1. You mentioned a DNR but no living will. A living will might have given the staff more back-up so to speak.

2. As elkpark said, it is not enough to execute a living will you have to discuss it with your family and your physician and they have to agree.

3. The family did not clearly understand what hospice was about or they might never have agreed to admit him in the first place. That happens often.

4. We all have to do a better job of discussing end of life care especially healthcare professionals. Unfortunately many of us are no better at it than the lay public. And the recent death panel nuttiness has definitely put another screw in it. So there will be more needless suffering.

[elkpark]

What happens fairly often is a relative who's not been involved with the Pt now comes into the picture and wants to run things....................no matter what the Pt may actually want.

This is so common that the legal department of the last big hospital I worked for actually had a pet name for the phenomenon -- "Cousin Susie from Dubuque." The client is in the bed, dying, comfortable, everything's going according to plan, and then "Cousin Susie from Dubuque," who hasn't seen Uncle Abner in twelve years or so before this, comes flying in, parks herself by the bed and says, "Oh no, I want everything done for my dear Uncle Abner ..." and suddenly everything's gone pear-shaped. (I was on the psych consultation-liaison team of the hospital, so we were also involved, along with the legal department, in these situations.)