DNR Grey Areas

[RNtoThe3rd]

Hi all,

I am venting because I have to go back to work for the next 2 nights and need support.

Last night, I came on my shift. The previous nurse informed me that my future patient made herself DNR/DNI 10-15mins before I came in. Not a problem. However, at the end of the conversation she further went on in telling me that the patient needed her Life Vest back on as she was soon to get a defib later in the month. During report, her monitor was striaght bigemeny with 6-beat, 8,beat, 10-beat runs of V-tach. At this point, a red flag went up. I'm thinking either (A) she doesn't understand her Life Vest or (b) she didn't understand her DNR order. I asked the nurse if she was a strict or soft DNR. (At our hospital, you can be either 'DNR and REFUSES antiarrhythmics/vasopressors/cardioversion/defib' or you can be 'DNR but ACCEPTS antiarrhthmics/vasopressors/cardioversion/defib.') Needless to say, she was a strict.

I went into the room and greeted my patient. I then went on and said I heard you need help with your life vest. She went on and said that the doctor said to have it on and she WANTED it on in case she needed to be shock. I then went on and said "Mrs. So-So, l have a serious question. I see, at the moment, you are wearing our pads. Now, if your heart goes into one of those lethal, but shockable rhythms your vest normally would shock...say you don't have your vest on....would you like me or any other hospital personnel to shock you?' "Absolutely, yes!" Was her reply. At this point, I closed the curtain and sat down with her. I asked her about her new code status and what it meant to her. She informed me she did not want the tube nor did she was compressions. I told her that was fine but I wanted to explore what a strict DNR was, what she was. After (literally) 30 minutes of educating what vasopressors (btw, she was SBP 60-80s), antiarrhythmics and shocking was she told me she wanted all those things, just not the CPR. Thinking this would be an easy fix, i approached my Resident.

I went to my Resident, concerned, and asked if he wouldn't mind stopping by my patient's room and speaking to her about her code status that there was a grey area. I explained to him I educated the patient and she wanted to be DNI/DNR but accept shocking. His first response? "Why did you even question the order?" I was taken back. I simply explained the above. His next response? "You do realize the resident who had the discussion and put it in went home for the day...we'll have to wait till tomorrow." This is when I got upset. I informed he that HE was the doctor now and this is what the patient WANTED. He then continually and condescendingly kept saying how wrong I was for even questioning it...how I should've never asked her...I finally just said "My job as the nurse is to be the patient's ADVOCATE...I am advocating for her and she wants a chance to get out of here. She wants to be shocked she is being as clear and I'm trying to be clear." Finally he waived me off and said he would go.

He was very condescending to the woman telling her it's not possible. There was a communication barrier with him and I think he was just getting frustrated. He kept telling her it was Full Code or no code. At this point, I said to the woman that if she wanted to call her POA I would be happy to call her. The woman said no multiple times and said wait till the morning. :mad:Finally, after frustration, she said she would be a Full Code till AM and that's what he did. WHen he left, she told me that's not what she wanted.

I went to my manager (who was leaving in 10 mins) who was in another unit and explained the situation. She was on my side. I went to the fellow who said she would be around but that entire night, she was putting lines in the ICU all night.

Change of shift comes around and I'm handing her back to the AM RN. I explained to her that we NEED to change this status because she does NOT want to be full code and to ask her team. She went right up to their report and informed them. I was summoned. THe nurse brought me over and my Resident said clairfy. So once again, I said "The patient wants to be a DNR/DNI that ACCEPTS, not REFUSES...that's all." My resident lost it. He started saying I was changing my story, how I was a liar, how I approached him and said he needed to change her status completely...meanwhile I'm introjecting explaining I NEVER said full code. He kept putting his hand in my face and waiving me off, looking away, smirking and giving me a condescending laugh. After 10 minutes of calling me a liar, he told I was done here and we all agree that you changed your story because I didn't know what the patient wanted. I finally lost it and told him he needs to stop disrespecting me and speaking down to me and that he called me over for a reason and I will not be treated as such and he needs to work on his communication problem because he is not hearing me nor the patient.

Needless to say, after I signed out I went to the big boss who just so happen to bring the Head MD of the ICU into the office. I was shaking and upset because I was so offended that I would be called a liar when all I was trying to do the entire shift was advocate. I explained the situation and I'm glad I went because they were both very supportive and said I did the right thing.

I know I probably should've called the attending that night and said something. I wrote a note in the computer before my resident explaining everything I said to the patient and everything she did. I'm just so upset because even though I did the "right thing," I can't stand being disrespected like that. I know I'm only almost 3 years out and will see this my whole career but...can anyone give me advice what I can do better next time? What I can say better next time? I am open to criticism, i really am. I know I just have to work on my tough skin. Ugh! Thanks for letting me vent!

[nurseprnRN, BSN, RN]

you done good. :yeah:the resident's butt is going to be in the fire and he knows it, so he went off on you. i wouldn't give him another moment's thought.

[SuesquatchRN, BSN, RN]

You did good.

[relgis15]

God this made my blood pressure go up. Stupid, arrogant, &*$&%($(**&Y$&&*%*(&$&$#^(^&^(@%&^# residents that think they know EVERY &^*&Y*^&%% thing. UGH

You did an awesome job. Way to go to bat.

[SilentfadesRPA]

Fantastic job with both the patient and a ego maniacal narcissistic resident. Only wish you the best in holding up your sense of self and develop a true feeling of pride.

I wish I worked with you.

Marc

[Creamsoda, ASN, RN]

You did great. I don't think you need to have tougher skin. You did your best, but I'm sorry that idiot resident, was an idiot. (I really do respect our MD's and residents, but this one sounds like a moron). There clearly was a language barrier, but also he seemed to act like you were the "lowly nurse". I wouldn't let that man take care of me with a 10 foot pole. I would have gone off on him too. In front of his attending.

[pockunit, ADN, RN]

What a ********. He knows he made a mistake, he knows he's going to be called on the mat, and he was trying to get you to admit you made a mistake so he could clear his name. Good for you for sticking to it and following through. The resident is a terminal douche and that may never change, but now you've seen his true colors and know how carefully you have to document over stuff with him.

[leslie :-D]

it sounds like you did awesome...for yourself and your patient.

even though you verbally explained your case, i'd still follow up in writing so this idiot resident has something in his file.

it really is worthy of an ir.

your pt thanks you

leslie

[carolmaccas66, BSN, RN]

- Next time, state your case - if the resident doesn't listen, fine.

- Get it ALL documented in the patient's medical record and/or on computer - write down everything that was said when and by whom, dated etc.

You did good going to your superiors.

- This Dr has THE GOD complex where HE WILL NOT BE QUESTIONED by such inferiors as nurses! And yet we spend 100% of time with the patients??

- Go immediately over the resident's head & complain to his superiors. That is what I used to do and it works.

- The resident sounds like a bully.

This is exactly why I put some opinions on here that nurses are still not seen as professionals, certainly not be doctors anyway.

I think you did great.

Oh and BTW there is NO WAY he would have been shaking his hand/finger whatever in my face. I would have had to grab his hand and asked him to stop doing that. But that's me; I've never tolerated piggish behaviour like this ever.

I would have told him what I thought of him actually.

[Esme12, ASN, BSN, RN]

What a jerk!!! If I had a penny for everytime some resident or half baked egotistical MD said I was through and they'd "have my job" I'd make warren Buffett Look like a pauper....and you know what they say about MD's with big egos don't you??? Well it means they have "LITTLE" to brag about....

Your job is to advocate for your patient.....and you did just that!!!! You should be proud! Doing the right thing isn't always easy......but it's still the right thing. :heartbeat

If you don't make waves...you aren't swimming!!! Just saying....

[xtxrn, ASN, RN]

Per the TOS, I can't reply as I'd like to.....

:hug:

[RNtoThe3rd]

Thank you all for your support...I had a spare minute to read and I thank you! I have nothing but the utmost respect for doctors and respect for them. However, I am such a mother hen when it comes to my patient's safety I will protect that patient as would all nurses. Messing with me is one thing but my patient or even worse...both?? I'm just mad about being disrespected in front of my fellow colleagues and his.

Quick Update: My note in the computer was written and accepted at 1953 stating what the patient wanted in quotes and how I educated about everything. The resident didn't write his until 2 AM and he wrote "made full code but wishes to be DNR/DNI." Yes, the attending saw this. I came back on and she is the proper DNR/DNI status (only accepting shocks and drugs). I was also informed that some of my senior nurses witnessed the event and had written emails as well and apparently he was doing other unsafe stuff; formal complaint was written about him.

I'm very happy that I had such a great supporting crew here and at work--it's truely and honor to be a nurse with you all!

It's funny, you learn you are the patient's advocate in school but when the words "I am the patient's advocate and I am advocating for her" came out of my mouth, I felt a huge sense of pride in being nurse.

Thank you again and I will keep swimming :)