Case Study...

domsmom · Nov 7, 2006

This is a case study that was given to me by my professor...anybody here who can help me to decide to solve this case...
Title: Letting Be
Jason is 71 yrs. old and adamant about not being resuscitated. "When my time comes, let it come! His wife tells all of you that she wants everything done for my husband." There have been team conferences and sensitive counseling. Still each of them is firm and the nurses are concerned over.
Question: What is right to do if Jason has a cardiopulmonary arrest? His doctor refuses to write a " do not resuscitate" order.

This sounds like a case for the ethics committee.

If there's no written DNR order or an advance directive, the client would be a full code. The doctor should listen to his client and write the DNR order.

AuntieRN · Nov 7, 2006

I agree, if the pt is competent then his wishes should be followed. I would definately call in the ethics committee on this one. I do not understand what the thought process is behind not honoring a competent patient's wish to be a DNR.

The nurse could also have a social worker or case manager (this is how we do it where I work) assist the patient in filling out an advance directive. Although there would still be the issue of no written DNR order.

moskeetus · Nov 8, 2006

Surprisingly..... I had exactly the same scenario for an assignment on Law and Ethics subject in my nursing school, except the patient's name (you may be doing the same course which I have done!). The details of the law may vary according to where you work, but in Australia, general consensus seems to be that there should be a correct Advanced Directives form filled by the patient (for NFR), and a NFR order by a treating medical officer should also be written up on the chart. With the presence of legally valid Advanced Directives for NFR, resuscitation cannot be done since NFR is what the patient has consented for, and the attempt to resuscitate will be considered to be an assault or battery to the patient. The key is "legally valid" Advanced Directives. If there is no Advanced Directives filled out and the patient has arrested (again, depending on which state/country you're working in, but generally) the healthcare provider has to resuscitate the patient according to "the doctrine of necessity/ doctrine of emergency" otherwise not resuscitating the patient can be against the duty of care. It means that under the circumstance of no clear NFR directives from the patient, the healthcare team would have to proceed in the best interests of the patient with the assumption that the saving life is his best interest. Also, if there is no Advance Directives filed, and the patient suddenly loses his capacity to make his own decision (e.g. falls unconscious), a surrogate decision maker will be appointed (usually the patient's next of kin - in this case, it would be the wife), to make healthcare decisions for the patient. Or, an Advanced Directive can be prepared to appoint a surrogate decision maker in advance. The healthcare providers have to resuscitate the patient if the surrogate decision maker decides that it is in the best interest of the patient. This is as far as I know about the answers for my assignment.

Dinith88 · Nov 8, 2006

This is a case study that was given to me by my professor...anybody here who can help me to decide to solve this case...
Title: Letting Be
Jason is 71 yrs. old and adamant about not being resuscitated. "When my time comes, let it come! His wife tells all of you that she wants everything done for my husband." There have been team conferences and sensitive counseling. Still each of them is firm and the nurses are concerned over.
Question: What is right to do if Jason has a cardiopulmonary arrest? His doctor refuses to write a " do not resuscitate" order.

THis is a no-brainer. If the guy is competent, you go by his wishes.

UNfortunately, this is a hypothetical question (right?). However, if the situation were REAL then forget the ethics committe...someone needs to confront the doctor...and paddle his orifice a bit if he still refuses. I cant imagine any doctor that WOULDN't write a DNR for a 71yr old, competent, man. If, after paddling the doctors butt, he still refuses...i'd inform the patient, and tell him he'll need a new doctor if he wishes to be a DNR...until he finds a new one who will honor his wishes, we'll break his ribs, stick tubes in his face, and electricute him.

Of course, this does need to be reported to ethics...but that whole process can drag on for a bit, and we need a solution to this problem asap. And the doctor needs to clarify his (wrong) reasons why he wont write for DNR despite the wishes of the patient.

Perhaps the best answer to your question would be to document clearly (and often) the guy's wishes. If he arrests, you call a code and tell the responding physician the guy's wishes. Then you've washed your hands of it. The guilt/blame/stupidity/injustice will then be on someone else's hands rather than your own. Unfortunately Our(nurses) hands are legally tied if dr refuses DNR...regardless if the decision is immoral or retarded.

Rocky_LPN · Nov 15, 2006

THis is a no-brainer. If the guy is competent, you go by his wishes.

you would??? and u would end up infront of ur BON. If there is no DNR on the chart or in my hands that man would be a full blown code!

Dinith88 · Nov 15, 2006

you would??? and u would end up infront of ur BON. If there is no DNR on the chart or in my hands that man would be a full blown code!

Ouch. Before you send me to nurse-jail, re-read my post...especially the last part...

VickyRN, MSN, DNP, RN · Nov 15, 2006

Perhaps the best answer to your question would be to document clearly (and often) the guy's wishes. If he arrests, you call a code and tell the responding physician the guy's wishes. Then you've washed your hands of it. The guilt/blame/stupidity/injustice will then be on someone else's hands rather than your own. Unfortunately Our(nurses) hands are legally tied if dr refuses DNR...regardless if the decision is immoral or retarded.

Excellent advice, Dinith88.

SEOBowhntr · Jan 30, 2007

THis is a no-brainer. If the guy is competent, you go by his wishes.
you would??? and u would end up infront of ur BON. If there is no DNR on the chart or in my hands that man would be a full blown code!

I agree 100% morally with Dinith. At least when you went home, you could look yourself in the mirror and still respect yourself.

I think the best thing to do in the situation would be to notify the ethics committee of the facility, or the Chief Medical Officer of intervention. Sadly, dead men never sue, but their widows do, and our whole practice is RULED by this. Out of respect for such a patient, I'd go whatever cost to ensure his wishes were respectfully followed, even if that was in spite of his wife's wishes.