I work at a Rehab SNF. We have this patient that was recently diagnosed with end stage cancer. The patient is conserved and was previously a full CODE ( or may still be one.)
My question is: Is the patient a full code if you have a signed DNR POLST by the doctor but no signature of the conservator? According to SSD notes, the conservator has been Faxed the POLST many times, voicemails have been left for the conservator and one SSD note states that the conservator needs to get a supervisor to sign the POLST.
If this patient codes what do I do? My DON has been telling the nurses that she is legally a DNR because we have a doctors order.
All meds for this patient's HTN and other conditions have been stopped and all we have to give is Roxanol. Should the meds have been stopped before we had a signed POLST?
it sounds like this pt is a ward of the state, and conservatorship was appointed.
in some cases, the conservatee has a right to participate in their healthcare decisions.
more likely the case however, is the conservator having exclusive rights.
i've seen pts w/conservators (pts being mentally disabled) being treated substandardly...
as if mentally impaired have no rights at all.
and this tx was initiated by the dr.!!
if one cannot personally reach the conservator, i would try to contact an involved atty (it may even have to go back to court itself...for an emergency hearing w/the judge.)
this is clearly social services job.
i'm thinking the ombudsman would also be another resource to pursue.
still, this pt is terminal, and so, comfort care is warranted and reasonable.
i'd just be curious to know if this pt is so incapacitated, that s/he doesn't have a voice in any of this?
Specializes in Gerontology, Med surg, Home Health.
We have guardians who will not sign a DNR without a court order. What's the point of being a guardian if you don't make important decisions? Who would suspend a nurse for questioning a code status? I have a feeling there is more to that story.
When I was a new nurse working in the hospital, a patient and their family asked me to tell the MD he wanted to be a DNR. Off I went to tell the doc. He told me to find an incident report. "Whatever for?" I asked. He hollered, "No NURSE is going to tell me to make one of MY patients a DNR." "Not my idea, doctor, but the patient and family are afraid of you and asked me to bring it up. I will not get an incident report." My supervisor heard the whole thing and was totally on my side. The doctor was just a bombastic idiot but luckily, the patient didn't have to suffer.
In our state a POLST is a form published by the Dept. of Health. It is different than a living will or advance directive. Another source of information may be found from your Dept. of Health.
Specializes in Infusion, Med/Surg/Tele, Outpatient.
We too have this debate at our hospital. I think the consensus was that the MD can make the pt at DNR all he wants, but without the pt's, NOK's, or POA's signature on the DNR .... when this comes up in a lawsuit, you have nothing to prove the pt/family consented to the DNR.
To OP: don't mean to hijack your thread but need to post this info.
To Onaclearday: Don't know what state you are in but note to all check with someone who is intimately familiar with regs in your state regarding requiring a DNR for hospice admission because in Florida it is ILLEGAL to require patients have a DNR for hospice admission. Granted be assured we strongly advocate for a DNR but we are not allowed to require it.
We have guardians who will not sign a DNR without a court order. What's the point of being a guardian if you don't make important decisions?
It's my experience that court-appointed guardians will sign POLSTs for their wards only if that person's wishes were known ahead of time. Otherwise, since these are third parties assigned when there are no other reliable people available to care for the ward, they cannot take the word of the person who is unable to make decisions for him or herself and have no one else to ask. As they do not and cannot know what the wishes were in the absence of written and witnessed advance directives and have no right to decide for themselves.
Who would suspend a nurse for questioning a code status? I have a feeling there is more to that story.
Yes, I suspect the same.
When I was a new nurse working in the hospital, a patient and their family asked me to tell the MD he wanted to be a DNR. Off I went to tell the doc. He told me to find an incident report. "Whatever for?" I asked. He hollered, "No NURSE is going to tell me to make one of MY patients a DNR." "Not my idea, doctor, but the patient and family are afraid of you and asked me to bring it up. I will not get an incident report." My supervisor heard the whole thing and was totally on my side. The doctor was just a bombastic idiot but luckily, the patient didn't have to suffer.
An incident report, huh? Did he think your DON and administrator would take THAT seriously?? :)
The good news is: patient is still alive and breathing and is not in any pain. The bad news: the patient still has an ambiguous code status and a "spontaneous fracture." My heart started racing went I was notified of this just happening from no cause. The doctor was called from a previous shift and the patient was x-rayed. I called the doctor with the xray results, patients pain under control, and details of the unsigned DNR POLST.
The MD was like"ya,ya it's ok. We'll just have PT splint it." no concern over the unsigned DNR by the state conservator.
This patient is State conserved, but the family came out of the woodwork this last week. The family is allowed to have medical info, per the conservator, but can't make medical decisions. They want the patient to be comfortable & are ok with the patient being a DNR.
The higher up's are walking on egg shells like there is a law suit in the works.
Today is Monday, so maybe the DNR will get signed.
Mine, is that I would not admit under the situation the Op was in (I don't have to). No DON/MD can shove an ambiguous/incomplete DNR form at me and pressure me to do anything. You see, I would as well need to know where I stood as a caregiver with this patient as hospice, calls of change in condition come directly to me. This MD having discontinued all meds... depending on the co-morbidity severity and possibility of those meds, and what the hospice diagnoisis is, what the "wishes" for hospice are... you see these things probably have not been discussed. Yes, hospice can be flexible to many variables, but must never be ambiguous. Everybody must be on the same page, for obvious reasons.
leslie :-D
11,191 Posts
it sounds like this pt is a ward of the state, and conservatorship was appointed.
in some cases, the conservatee has a right to participate in their healthcare decisions.
more likely the case however, is the conservator having exclusive rights.
i've seen pts w/conservators (pts being mentally disabled) being treated substandardly...
as if mentally impaired have no rights at all.
and this tx was initiated by the dr.!!
if one cannot personally reach the conservator, i would try to contact an involved atty (it may even have to go back to court itself...for an emergency hearing w/the judge.)
this is clearly social services job.
i'm thinking the ombudsman would also be another resource to pursue.
still, this pt is terminal, and so, comfort care is warranted and reasonable.
i'd just be curious to know if this pt is so incapacitated, that s/he doesn't have a voice in any of this?
op, let us know what happens...
leslie