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coincidence, I was working when the hospice floor called the ER and wanted to transfer a patient to the ED because he rescinded his hospice care and he ended up being my patient again.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 This is when we get a call in the ED that the patient rescinded his hospice care and is being transfered to ED so he can be admitted to regular room, as a FULL CODE!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.
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.
Some patients view IV fluids as "extraordinary means" and/or as artificial nutrition, and specify in their DNR/DNIs that they don't want them. It's also in what I call the hospital's "prefab" living wills - you can select that IV fluids, which will in essence prolong life (you'll die of dehydration b/f starvation), are not wanted.
Been there, done that, cried all over the tshirt.....
To cover yourself, document, document, document. I've seen these same kinda folks threaten to sue everyone in sight when someone dies from the end stage terminal whatever, since they're sure we "killed them" because that's what we do to dying patients....
can someone explian to me how can the md get sued if the patient's wishes are on paper and signed, it's really difficult for me to understand that family members may come as they please and have everything turn the other way around when the patient has already done that for him/her self. how are they liable (sp?) if they're doing what the patient has signed as okay for them to do? it just blows my mind. . .
I'm curious - can a patient reverse the decision of their family members?
84-year-old lady with severe AF, CCF that's going down hill very quickly (2 episodes of acute pulmonary oedema in less than three months, despite fluid restrictions etc), mitiral and tricuspid regurgitation causing severe breathlessness and COPD with CO2 retention. Admitted to hospital with acute pulmonary oedema, ? chest infection, increasing shortness of breath and rapid decline in mobility and ADLs. The patient is not confused nor demented, she's not stupid or intellectually disabled.
Day three of admission to CCU, cardiac reg phones niece (close relative, involved in care) wanting to know what the families wishes are in regard to mechanical ventilation and resuscitation in the event of an arrest. Medical team explain that pt's lungs aren't recovering from the fluid overload as well as they had in the past and may not. Pt can't maintain sats without continuous CPAP and despite CPAP has been CO2 overloaded more than once during the admission. Niece states that she wants all measures - including mechanical ventilation, if it comes to that, to give her lungs a "break" and see if they can recover. Medical staff nod, document and put the orders in place.
Can anyone see anything wrong with this?
No one asked the pt - the 84-year-old lady stuck behind a CPAP mask (so she can't eat any chocolate, which she'd like) who has been pricked with needles several times a shift without being told why/what for has no real idea of what is wrong with her - simply because no one has told her - no one has asked her whether she wants to spend the end of her life with a tube down her throat breathing for her, without an opportunity to say goodbye to her sister or kiss her great nieces again. No one has explained that hospice care is an option. No one told her anything at all.
Instead, family went ahead and made the choice for her. Neither family nor medical staff consulted the patient.
As a nurse - and an advocate for your patient - what would you do here?
can someone explian to me how can the md get sued if the patient's wishes are on paper and signed, it's really difficult for me to understand that family members may come as they please and have everything turn the other way around when the patient has already done that for him/her self. how are they liable (sp?) if they're doing what the patient has signed as okay for them to do? it just blows my mind. . .
it doesn't matter if the "family member" can win, they can still sue and cost the doctor thousands in time and money.
Specializes in Peds Critical Care, Dialysis, General.
My mother was quite explicit in her wishes when she was diagnosed with her cancer 2 years ago. I was difficult for Daddy to sign the DNR when Hospice came by, but he did and we all agreed to stick with her wishes.
When a loved one truly begins to die, it becomes hard not to intervene, and we could have - Hospice had a form we could sign to rescind all prior orders and seek more aggressive treatment if we desired. We respected her wishes and let her go in the manner she wished.
So, as others have expressed, family members can rescind the DNR, the advance directives. Doesn't matter about the validity of the claim, just the aggravation and damage to the doctor's reputation. Just think about how many ridiculous claims are made by the nitpicky families and dedication to the all important PG scores.
I truly hate it when a person's wishes are overridden because the doc won't advocate for the patient.
On the bright side, I can't remember exactly when but it was within the past year, I read about a case in NH where a doc did refuse to reverse the living will and the patient died. Family tried to sue, the judge threw them out of court saying the man was competent when he signed the living will and they had no business changing it.
I wish this would happen more often, then families would maybe start getting the idea.
I'm curious - can a patient reverse the decision of their family members?
84-year-old lady with severe AF, CCF that's going down hill very quickly (2 episodes of acute pulmonary oedema in less than three months, despite fluid restrictions etc), mitiral and tricuspid regurgitation causing severe breathlessness and COPD with CO2 retention. Admitted to hospital with acute pulmonary oedema, ? chest infection, increasing shortness of breath and rapid decline in mobility and ADLs. The patient is not confused nor demented, she's not stupid or intellectually disabled.
Day three of admission to CCU, cardiac reg phones niece (close relative, involved in care) wanting to know what the families wishes are in regard to mechanical ventilation and resuscitation in the event of an arrest. Medical team explain that pt's lungs aren't recovering from the fluid overload as well as they had in the past and may not. Pt can't maintain sats without continuous CPAP and despite CPAP has been CO2 overloaded more than once during the admission. Niece states that she wants all measures - including mechanical ventilation, if it comes to that, to give her lungs a "break" and see if they can recover. Medical staff nod, document and put the orders in place.
Can anyone see anything wrong with this?
No one asked the pt - the 84-year-old lady stuck behind a CPAP mask (so she can't eat any chocolate, which she'd like) who has been pricked with needles several times a shift without being told why/what for has no real idea of what is wrong with her - simply because no one has told her - no one has asked her whether she wants to spend the end of her life with a tube down her throat breathing for her, without an opportunity to say goodbye to her sister or kiss her great nieces again. No one has explained that hospice care is an option. No one told her anything at all.
Instead, family went ahead and made the choice for her. Neither family nor medical staff consulted the patient.
As a nurse - and an advocate for your patient - what would you do here?
Well, again, technically, it's not a question of whether she can reverse the family's choices -- if she (the client) is A&O and competent, she is the one who should be making the choices and decisions, not the family. Have you raised this issue with the physicians? Your nursing chain of command? What is your facility's policy/procedure for requesting an ethics committee consult, or asking the legal department's opinion?
can someone explian to me how can the md get sued if the patient's wishes are on paper and signed, it's really difficult for me to understand that family members may come as they please and have everything turn the other way around when the patient has already done that for him/her self. how are they liable (sp?) if they're doing what the patient has signed as okay for them to do? it just blows my mind. . .
unfortunately, you can sue for any reason, and because we don''t have "loser pays" it will cost you thousands of $$ if you do get sued. (happened to me over something unrelated to work, and the plaintiff had the case dismissed w/prejudice when it came time for my lawyer to depose them. my legal bill was about $8 grand.)
so, many times claims with little merit are settled simply to avoid the time and trouble of the lawsuit. (i might have settled for a couple grand if the plaintiff wasn't greedy, and didn't accuse me of fraud.)
i wonder if the persons with anything worth inheriting, made it clear that if their wishes were not honored their will become null and void and all property/money went to charity that that would work????
ugh. i see this all the time being in LTC. one thing i always tell the family member is that one of the hardest things to do as a child is to abide by your parent's wishes if they have chosen no acute care. and that works about 1 out of 100 times.
you just want to grab these people by the shoulders and say "omg do you not see you are torturing your mother???"
carolinapooh, BSN, RN
3,577 Posts
Some patients view IV fluids as "extraordinary means" and/or as artificial nutrition, and specify in their DNR/DNIs that they don't want them. It's also in what I call the hospital's "prefab" living wills - you can select that IV fluids, which will in essence prolong life (you'll die of dehydration b/f starvation), are not wanted.