DNR and patient advocacy

[pepper_rn]

First, let me begin by saying that I do not believe that DNR should translate into "Do not treat." There are plenty of people out there with active DNR orders or living wills in place who can and should be treated effectively. But I had a case last night that really made me question the line between following those orders and patient advocacy. Some back story, this patient has been in and out of the ICU for 6 weeks. The patient had a surgery that went badly, went septic, into renal failure, exacerbated CHF and eventual respiratory distress requiring intubation and dialysis. After recovering somewhat, the patient signed a DNR order and expressed wishes to NEVER be "put back on the tube again." But the patient never addressed dialysis. Once transferred from our unit to the step-down care area, the problems started again BUN rising, output all but stopping, respiratory distress. The doctors approached the family to begin dialysis again, but suggested that the patient be intubated and ventilated prior to placing the dialysis catheter. The belief was that she would "wear out" before dialysis treatment could begin. The family, after being told that they "had to give this person a chance" by the doctor, agreed to elective intubation. Basically because they were led to believe that it was for a procedure and not resuscitative. But the truth is, she would have died before we could've begun dialysis again so I do believe it was resuscitative.

The patient had been re-intubated for several days without the benefit of sedation. It was thought by the doctor that the patient was so far down on their own already that we shouldn't need to sedate with anything other than prn Morphine or Ativan. As I am giving the bath, suctioning and repositioning the patient woke up several times. Each time the eyes opened there were huge tears rolling down the cheeks. The patient would swing her head from side to side, bite down on the OETT and would mouth, "no, no, no" around the tube. It was so heart breaking. I went to the doctor with this information (and documented it thoroughly). His reply was to try and wean her from the vent, which of course she failed. This poor woman, who is so edematous that even her stretch marks are fluid filled, she is in pain and winces every time I touch her. Everything that I am doing to her, she has said she doesn't want and because the family agreed under false pretenses, I have to keep doing it. I tried speaking to the family, compassionately of course, to try and educate them on what was happening. But the doctor has them so hopeful that this will work that it is prolonging the inevitable.

I wouldn't even consider this a growing problem if I hadn't seen it so many times. I've heard doctors use the excuse, "well it's for a procedure, it's not her lungs that are killing her". And while there is some small truth to that, it's not the whole truth and families are left with the burden of not trying everything they could, or thinking that a parent could still be here if only...

I'm wondering at what point do we stop the doctors and become the patient advocate? How many different ways can you say and legally document what you don't and do want done and still have the expectation that someone will carry out your wishes? I know this is long, but I am truly heart sick over it. I was to the point last night where I really considering untying the restraint from her very swollen hand and letting her extubate herself. Which I know is wrong, so I decided to rant about it here instead. Anybody else have an experience like this.

Pepper

[DutchgirlRN, ASN, RN]

I have a home health patient living in an assisted living apartment and he is a DNR with limits. I don't think that's possible is it? That's more like a living will issue. He is very very confused. Since it says with limits I think I would feel obliged to perform CPR. I need to phone his daughter and find out just what "with limits" means.

[SuesquatchRN, BSN, RN]

I would fight for her - of course, I don't know what that would actually do to your standing on the ward and with your coworkers so I can easily say what I would do since I'm not there.

She's being tortured.

[galenight, BSN, RN]

I had a similar situation recently in the ER. I don't know that you can do anything differently. Right now your hands are tied. What we need is legislation entitling a patient to express his or her wishes in a legal document that is legally binding to the medical staff. The problem with that, of course, is the document has to be present at the time of the patients impending death. Families are so caught up in what they want.. they want mom to live longer, dad to go fishing one more time, sis to live to see grandchildren, that they can't seem to remember that these patients have/had wishes. Families can be selfish. Keep documenting and keep advocating best you can withing hte restrictions you face. Good luck.

[moonchild20002000]

I have a question. When the decision was made to intubate was the pt.competent to make that decision?Did the Doctors talk to the patient?

Isn't the pt telling you she wants this stopped?Why aren't the Doctors talking to her now?

I really think you have done all you can for your patient. I don't know what else you could do .I think you are in a difficult postion,I hope that peace will come soon for your pt..

I felt heartsick just reading the post.I have been through a similar situation with my mother.There was a time where my mother was intubated without sedation( I feel that is barberic.)and I refused to allow a feeding tube to be inserted.I also told them if she became extubated no reintubation.I was made to feel like I was contributing to her demise by the staff.My mother was end stage COPD and DID NOT want intubation and a feeding tube. She survived that episode.I tried to advocate for her,I would not back down. When she did die,it was peaceful,in her sleep,in her bed,as she wished.

Sorry to ramble on,I just feel that your pts wishes should be honored.

[lsyorke, RN]

I have a question. When the decision was made to intubate was the pt.competent to make that decision?Did the Doctors talk to the patient?

That is the big question here. What is the use of having a DNR initiated by the patient, which is than superceded by the family?? That defeats the whole purpose. In the above patient, this should be referred to the Ethics Committee of the facility for review.

[pepper_rn]

Thanks to everyone who has responded so far. I wanted to answer some of the really good questions that have been asked. When the patient was extubated the first time and began to recover she was lucid and compentent enough to make the decision to have a DNR status. She told everyone who would listen that she didn't want "that tube" again. Luckily we have a copy of that legal documentation on her chart. For the second intubation, she was pretty much unresponsive as a result of the renal failure for anyone to ask. My biggest problem is that I feel that if she has already expressed her wishes not to be intubated, then the physicians should not be allowed to even offer that to the family as an option for treatment. Essentially, the family shouldn't be able to over-ride a decision that she made when competent to do so.

And yes, I really feel that she is telling me that this needs to stop. And no, the doctors are not interacting with her at all. The tell me to give her more of the morvan slam (morphine and ativan) "to keep her more comfortable". To me, it's disgusting and this is not the first patient it has happened to.

Luckily all my co-workers support me 100%, so no problem going toe to toe with doctor, which I will continue to do. I will turn this over to the Ethics commitee at my facility. Unfortunately to my knowledge this will be the 7th case turned over and nothing has been done so far:sniff:

thanks again,

Pepper

[leslie :-D]

would your nm back you up, and confront the md who intubated her again? you know the conversation you had w/your patient. it was deceitful and manipulative on the md's part, and he took advantage of a fragile situation. highly unethical. i sincerely pray your pt. soon finds peace.

leslie

[TazziRN, RN]

Do you have an ethics committee at your facility? This sounds like something that should be brought to their attention.