DNR patient coded

[adventuregirl]

My patient today was a 93 yo women who had a pacemaker placed several days ago. She arrested on the table and 10 minutes of CPR was performed, and she was vented and sent to ICU. She is now on my step-down/tele unit, 5 days later. She has fractured ribs, a feeding tube, is very frail and weak, and needless to say, uncomfortable. I found out after my shift that she had signed DNR orders, as well as a DNR colored hospital braclet, prior to having her pacer placed ... in other words, everyone should have known she was a DNR. The nurse who informed me of this said Dr's don't like their patients to "die on the table", so they coded her. Has anyone heard of this happening? How can this be prevented? I fear for myself, and my own family going through this type of pain/suffering if my/their wishes are already expressed, and the Dr is aware. What does a person need to do to make sure their wishes are met?! I feel so sorry for this lady. I'm not sure the daughter has any interest in taking legal action, but what could be done if this was the case?

[rnmi2004]

The way it was explained to me is that DNR status has to be suspended for the patient to go to OR, because technically the intubation associated with a surgical procedure is a violation of a DNR status.

Does this patient have a POA? It seems to me that the POA (and the doctors!) should have taken into consideration the patient's prior DNR status before it got to the point where they placed a feeding tube.

[Katnip, RN]

In every facility I've worked (trying to recall any exceptions, and I can't...) DNR orders are suspended for OR.

Check your hospital's policies, and read through the anesthesia and OR consents. There may be a specific consent for this (we had a separate one for suspension of DNR status that had to be signed along with the others).

Same here. It seems in most, if not all facilities, that patients are not allowed to die in the OR. They can, however be allowed to die once they get to a room. Must have something to do with too much paperwork.

[EmmaG, RN]

For comfort, like tumor debulking, or hip pinning after a break. I wish suspended DNR's were not co common in the OR. It would at least be a peaceful death.

The recommendations made in the first link I posted make sense.

Recommendations

We have two recommendations. The first is that each department of anesthesiology should have a policy regarding DNR orders in the perioperative period.

The second recommendation is that, of the choices we have presented, we favor continuing all DNR orders during the perioperative period after discussing this

with the patient (Option D, above).

Although some believe that conflicts between the ethical, medical, and practical considerations cannot be resolved, recent developments have shown that uniform policies are feasible.

In October 1993 the ASA formulated their "Ethical Guidelines for the Anesthesia Care of Patients and Do Not Resuscitate Orders or Other Directives that Limit Treatment" (14). This policy acknowledges that automatically suspending DNR orders or other directives that limit treatment prior to procedures involving anesthetic care may not sufficiently address a patient's rights to self-determination in a responsible and ethical manner.

The ASA guidelines respect an informed suspension of DNR orders during the perioperative period if explicitly discussed with the patient or surrogate. The policy allows airway management and other treatment options, or will honor perioperative DNR orders if the patient so states.

Patient autonomy is upheld to the greatest degree with this approach. Professional integrity is maintained such that in cases of moral conflict "the anesthesiologist should withdraw in a nonjudgmental fashion, providing an alternative for care in a timely fashion."

Distributive justice is served in that an open discussion of options, resources, and outcomes should ensue with the patient and family or proxy. The American College of Surgeons has recently adopted similar guidelines (14).

These statements provide important groundwork from which each hospital can develop policies to address the issue of perioperative DNR orders.

[oramar]

The recommendations made in the first link I posted make sense.

Recommendations

We have two recommendations. The first is that each department of anesthesiology should have a policy regarding DNR orders in the perioperative period.

The second recommendation is that, of the choices we have presented, we favor continuing all DNR orders during the perioperative period after discussing this

with the patient (Option D, above).

Although some believe that conflicts between the ethical, medical, and practical considerations cannot be resolved, recent developments have shown that uniform policies are feasible.

In October 1993 the ASA formulated their “Ethical Guidelines for the Anesthesia Care of Patients and Do Not Resuscitate Orders or Other Directives that Limit Treatment” (14). This policy acknowledges that automatically suspending DNR orders or other directives that limit treatment prior to procedures involving anesthetic care may not sufficiently address a patient’s rights to self-determination in a responsible and ethical manner.

The ASA guidelines respect an informed suspension of DNR orders during the perioperative period if explicitly discussed with the patient or surrogate. The policy allows airway management and other treatment options, or will honor perioperative DNR orders if the patient so states.

Patient autonomy is upheld to the greatest degree with this approach. Professional integrity is maintained such that in cases of moral conflict “the anesthesiologist should withdraw in a nonjudgmental fashion, providing an alternative for care in a timely fashion.”

Distributive justice is served in that an open discussion of options, resources, and outcomes should ensue with the patient and family or proxy. The American College of Surgeons has recently adopted similar guidelines (14).

These statements provide important groundwork from which each hospital can develop policies to address the issue of perioperative DNR orders.

The problem here is that the goverment publishes list of the death rates according to surgeons and hospitals and anesthesiologist. If these doctors allow these patients to die in OR then it is like a black mark against them. Not only do the surgeons and anesthesiologist refuse to to recognize a DNR but when I worked rehab, ortho surgeons used to try to get their patients who were in poor condition out of the hospital where the surgery was done and to another facility before they died. That way the surgical death was not counted against them or the facility where the surgery was done. I think the list of deaths is unreasonable and is producing these borderline unethical behaviors. Perhaps the federal goverment should try another approach.

[TinyNurse, RN]

In every facility I've worked (trying to recall any exceptions, and I can't...) DNR orders are suspended for OR.

Check your hospital's policies, and read through the anesthesia and OR consents. There may be a specific consent for this (we had a separate one for suspension of DNR status that had to be signed along with the others).

I agree.

[PoppaD]

ditto