Code Status Error - An Ethical Dilemma

Simkah

I was a relatively new and inexperienced nurse and was orienting to the hospital on a chaotic medical-surgical unit. The orientation began by following the nursing assistant(s) for a shift and participating in basic patient care tasks. This was to promote better team playing among the members of the nursing care staff and empathy for the nursing assistant role. As I was functioning in the role of a nursing assistant and did not have much experience with this particular floor (it was my first day at this new job), I was a bit vulnerable. The nursing assistants were not given much of a patient report. I did not have time to look over the patients' charts or Kardexes, but just hurried from room to room as I followed the nursing assistant to help her with the many patient care tasks on this busy medical-surgical floor.

One of our patient assignments was an elderly gentleman with dementia who was also a double-amputee. As we were turning him to the side, to give him his bed bath and to clean up bowel incontinence, he suddenly began gasping and his breathing became erratic. It was obvious that he was going into respiratory arrest. We repositioned him with his head up high in the bed, tried to stimulate him to get him to breathe, placed oxygen on him, and called for help.

When the charge nurse arrived shortly afterward, she made these caustic remarks: "Don't revive him. Take the oxygen off. Let him go. He's a DNR (do-not-resuscitate). If you were him, would you want to live?" Since I believed the charge nurse had accurate knowledge of all the patients' code status on the floor, I obeyed her orders without question. I was not the patient's primary nurse and did not have accurate knowledge of his code status. He could have easily been resuscitated at that point with an Ambu bag, oxygen, and some furosemide IV. But tragically, he progressed from respiratory arrest to full cardiac arrest and then died as we looked on helplessly.

The whole situation was very surreal, like a bad dream. About 15 minutes later, it was discovered that the patient was indeed a full code and should have been resuscitated! The patient's primary nurse (who afterward appeared on the scene) was very upset with the Charge Nurse for allowing her patient to die. I was a bit suspicious all along because this client was not wearing the required "DNR" armband. But many patients on this disorganized floor did not have on the proper code status bracelets.

After the shift was finished, I went home in a state of shock. I immediately telephoned the nurse manager for this floor (who had been off that day) and also the Director of Nursing (DON) to inform them what had transpired. I also dutifully wrote up everything that had occurred in a facility incident report. I point blank asked the DON if I should report this "failure-to-rescue" error and patient death to the state Board of Nursing (BON). She emphatically said, "No - we will take care of it." I also e-mailed one of the staff at the BON and asked her in the e-mail about a detailed "hypothetical" patient-care situation and if this should be reported directly to them. The BON official replied that following the "Chain of Command" in my "hypothetical occurrence" at the hospital was sufficient for them, but I could always directly report the occurrence to the Board if so desired. So I did not report the incident to the Board.

It turned out that the incident was "swept under the rug." I was devastated. The Charge Nurse was severely counseled but not fired. She retained her license and continued to practice on the floor. Nothing was ever reported to the Board. The patient's family was not informed of the true circumstances surrounding their loved one's death. I found out that this incident had been "kept quiet" to avoid bad publicity in the community. No doubt they also wanted to avert a huge lawsuit and big money payout by the hospital.

It was about eight months later that I became fully aware of the facility's inaction. I decided at this point to let it go. I knew "whistleblowers" in nursing often suffer severe repercussions and the case was now very "cold." I knew if I reported this incident to the Board, I would not be supported in my allegations and the charges would probably be turned on me. In fact, I possibly could lose my license as a result! Since my state is an "at will" employment state, I probably would be fired, then branded as a troublemaker and would not be able to find employment anywhere in the area. So I chose to remain silent. I still feel twinges of guilt that I had taken the "coward's way" out. But this seemed like the most pragmatic and reasonable thing to do at the time.

Of course, hindsight is always 20-20 and this happened a long time ago. I have experienced much personal growth since then and now possess business-world savvy as well as nursing expertise. If faced with a similar circumstance, I would demand proof of the patient's DNR status. Otherwise, I would immediately initiate the resuscitation ("Code Blue") process. I now know to directly and in a timely manner report such occurrences to the BON. Hospital administrators often choose to cover up healthcare errors and cannot be trusted to disclose these events to the proper authorities.

I would describe my decision-making process at the time as what I had been taught in nursing school - the "follow the Chain of Command" philosophy. I sought out the proper authorities at the hospital. I followed their advice and filled out the facility incident report. I trusted them to do the ethical and right thing. It turned out that they did not do so. I was not expecting this.

Code Status Error - An Ethical Dilemma

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