Do Not Resuscitate Order for suicidal patient

[mep726]

I have a question. I have a case study that I am struggling with. I have a patient who attempted to commit suicide by a self inflicted gunshot wound. His wife died a week prior and he left a suicide note stating he was too heartbroken to go on. He is non responsive, right pupil fixed and dilated. Very large extended family show up. A neurosurgeon was consulted and he says prognosis is not good even with surgery, however, family still wishes for the surgery to be done anyways. Once the patient is prepped and in the OR they receive a call that the patient signed a DNR order 2 days ago. AS the OR nurse what are your legal and ethical issues now? Do you honor the DNR or the family's wishes?

I have to explain what my legal and ethical issues are which originally I was leaning towards if there is a DNR order present then you honor that despite the circumstances because the man had to be found in his right state of mind when he signed, right? And if the patient needs surgery does that exemplify the DNR order? I have researches where some say yes and others say no.

[offlabel]

A DNR is not a mandate to participate in someone's suicide and it needs to be established by a person not under duress or distress, psychological or otherwise. The futile nature of the surgery is another issue, but if the decision not to go forward is significantly based on a DNR that was established by a suicidal patient, I would not consider that a squeaky clean call.

Up until recently, suicide in general was considered an irrational act. There are some organizations that subjectively (IMO) declare some suicidal planning and execution rational while at the same time conceding that other times it isn't.

This isn't a healthy situation when "of sound mind" can be contested amongst psych professionals.

[mep726]

My thing is how are we to determine if he was of sound mind two days prior...yes I know his wife died a week ago but how am I to judge that being an OR nurse?

[GrumpyRN, NP]

DNR does not mean Do Not Treat.

[mep726]

Yes, I understand this. That wasn't my question though. Its a case study and I have to tell why I would not honor the DNR order that is in place and if I do honor it then explain why and the legal and ethical justifications as to why.

[FolksBtrippin, BSN, RN]

Yes, I understand this. That wasn't my question though. Its a case study and I have to tell why I would not honor the DNR order that is in place and if I do honor it then explain why and the legal and ethical justifications as to why.

What exactly are you asking though? It does seem like you don't understand what DNR means.

The patient does not currently require resuscitation. So there is nothing to honor or not honor.

Your question: "Do you honor the family's wishes or the patients?" doesn't make any sense. The family's wishes are not in conflict with the patient's wishes.

DNR means--- If I die, let it happen. In other words, if my heart stops beating, don't do CPR. A DNR is not valid during surgery. Because the surgeon is doing stuff that can make the heart stop beating. So you always resuscitate on the operating table.

If the question is "Do we go ahead with the surgery?" Well, the patient's DNR isn't about whether or not to do the surgery. So yeah, you do what the next of kin wants. You don't make assumptions about what the patient would have wanted based on his suicide attempt. His suicide attempt is irrelevant here.

If the question is do I do CPR if he dies in surgery? See above. A DNR isn't valid during surgery.

If the question is, do I do CPR after he comes out of surgery in case his heart stops beating after he was stabilized? No, you don't. He's a DNR. His suicide attempt did not invalidate his DNR.

If the question is "Do I pull the plug?" That's a choice for the family too. You can't make assumptions based on his suicide attempt, or on his DNR.

I

[mep726]

As I said above that is what I was leaning towards as well but then I started doing research and found that in some cases that a DNR is yes exempt when it comes to the OR but then I have found some hospitals say a DNR is a DNR. I know what a DNR means, I am just answering the question as was put in the case study. I appreciate any and all of your input. We have had instances in my hospital where family has revoked the patients DNR; though I do not agree with this.

[brownbook]

This is an interesting philosophical issue. As a "lowley" OR nurse I'd let the "higher ups" deal with this...it's waaaay above your, or my, pay grade. This situation calls for a judge, lawyer, ethics committee, etc.

I can't imagine a situation where it would come down to an OR nurse having much say so in this situation.

I guess if this patient was brought to pre op you'd be within your right to say you personally weren't comfortable with the situation and decline to circulate or scrub in on this case if that's how you feel. Then could you be fired? That's an interesting question. I would certainly hope not.

[offlabel]

As I said above that is what I was leaning towards as well but then I started doing research and found that in some cases that a DNR is yes exempt when it comes to the OR but then I have found some hospitals say a DNR is a DNR. I know what a DNR means, I am just answering the question as was put in the case study. I appreciate any and all of your input. We have had instances in my hospital where family has revoked the patients DNR; though I do not agree with this.

Sounds like you've done your homework, you just need to process what you found out, form an opinion and write it down. And a DNR is always suspended if a patient is undergoing surgery and anesthesia. There isn't a CRNA or physician (in the US, anyway) that would perform an anesthetic under those conditions, if they're in their right minds regardless of what some hospital administrator says.

[MunoRN, RN]

This is a pretty common question in nursing school, although usually it asks about whether a patient admitted for suicide attempt can decline any or all interventions, not just DNR, and there's no definable correct answer. Views on this vary and have changed over time.

It used to be more common to view patients admitted for suicide as being unable to decline any treatments just based on their suicide attempt, although that seems to be shifting. At last couple places I've worked, suicide attempt patients can only be denied the autonomy other patients have if they are deemed to be legitimately unable to make decisions, or if their self-harm choices are being driven by untreated psychiatric factors. At least in my experience, the majority of these patients retain the right to decline treatment, including treatment of self-inflicted medical conditions.

Automatically rescinding DNR is also something I've seen change over time, there are certainly some situations where resuscitation is just part of the process, so it wouldn't be reasonable not to address that, but I pretty commonly see patients go to the OR or procedures where they maintain their DNR status throughout but with pre-agreed upon exceptions. There is actually a position statement on this from the American Society of Anesthesiologists:

policies automatically suspending DNR orders...may not sufficiently address a patient's rights to self-determination in a responsible and ethical manner. Such policies...should be reviewed and revised

Perioperative Do-Not-Resuscitate Orders | Journal of Ethics | American Medical Association

[subee, MSN, CRNA]

Futile treatment requests should be directed to the ethics committee. Families dictating medical care in this situation is crazy. There is nothing wrong with a surgeon refusing to do the surgery and referring patients to the bozo who will.

[Nurse SMS, MSN, RN]

I had a real patient very recently in a similar situation. The ethics committee determined that the patient was under extreme psychological duress at the time they made the DNR and could not be considered "in their right mind" at the time they made it. It also was discovered that legally, it had not been notarized and therefore was not a document that we could be bound to in any case.

The family's presence supersedes the DNR, which was likely more of an early suicide note and represents a state of duress rather than a logically thought out medical decision. In either case, the family would have the right to decide whether to proceed with the surgery or not and their wishes either way should be honored with as much sensitivity and honesty as possible.