Consent for intubation?

[PJMommy]

Ugh...I'm just so frustrated. Here's the scenario and I need opinions:

70-something y/o pt who is septic. Extubated 2 days prior. Lungs sound like crap...and he can't/won't cough or deep breath. Within 1 hour he goes from sats of 90 on room air...to sats in the 60s on 6L cannula. After vigorous nasal suctioning and being placed on 15L non-rebreather, he rebounds back into sats in the 90s.

Okay...docs decide the guy needs to be intubated again because he has no reserve and still won't be able to clear his lungs. Middle of the night...docs want to talk to family. Family member is in the hospital -- we find her, docs talk to her about "do you want to consent to the tube". (No DNR in place.) She wants the intubation. Fine.

Somehow I'm the bad guy here. Family member was hateful to me the rest of the shift. She can't believe we would "just let someone die". She talks to the manager and day CN in the A.M. and day charge later tells me I shouldn't have asked the family member b/c we don't need to speak to her before making the decision to intubate (although the docs actually talked to her). I argue that we have an obligation to talk to the family about this if the pt is stable. (I completely understand needing to do an *emergent* intubation w/o speaking to family.) I'm told that, without a DNR in place, there is no reason to talk to family prior to intubating. CN tells me repeatedly that she can see the family's point, etc. etc.

Were we wrong in speaking to the family prior to intubating this pt?

[bobnurse]

I encounter that all the time and i feel keeping the patient up to date is whats most important. many times the family is truly unaware of the patients condition and the next thing you know a doctor is saying we gotta intubate the patient....Family members feel the nurse should of informed them of the patients deteriorating condition. A consent is not needed for intubation if the patient is a full code, but in your situation where the patient is somewhat stable, disclosure to the family is highly important. Maybe thats why the family was upset with you. They feel you didnt keep them notified.......I keep family members up to date at all times. I never say " I think were gonna have to tube the guy in my opinion", but i tell the family things like "Im concerned over the patients respiratory status"

[canoehead, BSN, RN]

Good grief- you can't win. If you had intubated and family had come back and found it without any notification....well they would have been even more upset. And yes, sometimes we do "just let people die" and sometimes it is the kindest thing to do.

[Antikigirl, ASN, RN]

THe one time I had a very similar situation I told the family that they really needed to speak with the doctor right away and discuss the patients condition very seriously! I told the family that their loved one was not breathing well, and that the doctor made a choice to have them notified so they could be part of the desision making process, and that by no means were we going to sit back and wait till death...that in the case when finding the family was endangering the patient, the MD would have had to make the choice on their own...but since the MD felt we had time to contact you for your imput, that is what we did!

I am also a HUGE advocate for DNR's/POLSTS and remind MD's of this contantly! When we have those in place..it makes things a little easier. The POLST, used in a few states, is awesome..it really cuts to the chase about IV's, intubation, CPR, Defib, antibiotics, comfort measures..the works..but in one easy to read page! If I have a patient that doesn't have on..I almost insist they do! ESPECIALLY if they are on invasive or have a risk of being on a very invasive life saving treatment like intubation!

Well, that and I really talk to family about these topics when this type of patient is around! I really keep them up to date, and remind them that someone may have to reach them in a moments notice so I need all the updated phone numbers and what not for very quick contact. I let them know that they are a part of this process, and without them the patient doesn't get as represented as they should..and that I appreciate their sacrifice and help (I always bring it back to family being a positive force in treatment, that helps them to realize they are a part of it all!).

Good luck to you, and remember also that this patients family can be going through some very hard times with letting go or dealing with this..they can be in denial or even denial of their own roles in this. Don't take it too personally if you can help it (which can be so hard!), and definately document what was said so that other nurses don't get this either! And if you have time, try to find a way to use that good ol nurses critical thinking to come up with implementations to make contacting the family easier, and get that doc to have them make up a DNR!

[PJMommy]

Thanks for the responses. I'm a year on the job and always learning -- but this hoopla over contacting the pt's family really caught me off guard. Thanks again.

[Headhurt, ADN]

We use DNR on the charts (for folks who don't want to be coded), but we also have DNI (do not intubate). Usually they are listed together. I've never seen a patient/family member want one and not the other.