Dr revoked DNR

[sassysteph7]

Recently I was assigned to care for a 42 year old male who came in with CHF exacerbation. Upon calling the EMS he made himself a DNR and arrived to my facility with the golden ticket to heaven. Well the next morning the young doctor arrives and revokes his DNR. I was upset and told the dr that he had no right to do that as it was the patient's wishes. He said I was overreacting and that if the patient was vented this admission he'd recover and go home. I still did not agree and went about my shift. Well the very same patient, after caring for him for 4 days, required being vented on Sunday. I'm very upset with this and still do not feel that the dr had a right to revoke the DNR thus requiring me to call the dr and get him intubated. I'm new to the ICU and pray this doesn't happen often. Has this happened to any of you and if so, how did you handle it?

[meandragonbrett]

These kinds of ethical issues come up all too often in the ICU. You will experience it semi-regularly and it comes in various shapes: provider vs. patient, patient vs family, family vs provider, etc.

I've called the ethics committee many times in the middle of the night when these issues arise.

[Kymmi]

In the 4 days between when the MD revoked the DNR and the patient required intubation did anyone tell the patient that the MD revoked the DNR? If so did the patient agree with the MD decision to revoke it? Did the patient and the MD speak about the DNR issue and the patient possibily changed his mind? If the patient was alert/oriented and no one addressed the DNR status with the patient then thats where the first mistake lies. If the patient wished to remain a DNR after the MD revoked it then you would have had 4 days between then and the time of intubation to involve the ethics committee which is what I would have done.

Sometimes these issues come up quickly however it seems there was a 4 day window to clear this up unless no one bothered to inform the patient that the MD revoked his DNR against patients wishes. If that is the case then I'd say someone missed the boat on the chance to do what the patient desired.

[detroitdano]

What Kymmi said. Shift report should always contain code status and/or issues with code status. Lots of people missed a big issue here if he wanted to be DNR, was made a full code, and nobody had a problem with that.

[PMFB-RN, RN]

I was upset and told the dr that he had no right to do that as it was the patient's wishes. He said I was overreacting and that if the patient was vented this admission he'd recover and go home. I still did not agree and went about my shift.

*** You went about your shift? It is our job as RNs to be our patent's advocate. It doesn't sound to me like you where much of an advocate for your patient. I would have explained to the MD that what he did was wrong and that I intended to call the ethics committee immediately if he didn't do the right thing. I would also immediately inform the patient and any family members of this physicians actions and get your manager or house supervisior involved. Document EVERYTHING. You know you could be charged with battery by doing CRP on a patient who has already refused it?

[Bubbles_RN]

Yep an all too common issue in ICU. If you are new to ICU I would have suggested speaking to either your preceptor/nurse manager. They could have provided you with guidance as to what your next steps could be.

If a situation doesn't feel right listen to your instincts...they were telling you the situation was wrong. There should be hospital policies on what to do if you don't agree with the treatment plan.

Me - I would have directly asked the doc if he had discussed this with the pt. Alternatively I would have discussed why the pt wanted to be a DNR with the pt. Knowing why the pt made that desicion might have strengthened your position with the doc.

Good luck, I spent many a shift as a new ICU nurse feeling like I should be beating my head against the wall.

[TemperStripe]

Yikes. These are tough situations for everyone, and these are often the situations that have left me feeling the most stressed at the end of the day. I have had a handful of "ethically ambiguous" events, not exactly like this, but generally involving multiple teams with differing opinions of long term outcome vs. actual patient wishes. Go with your gut. The most important job we have is that of patient advocate. Do not be afraid to have a very frank conversation with the patient as well as the doc involved. Do not be afraid to address death with your patient; many times I think they are relieved that someone will talk about it realistically, and it makes it easier for them to verbalize their wishes. Seek out the guidance of other nurses, there's nothing wrong with that, either. Talk to the doctor privately so they don't feel threatened by your message. Try not to judge the docs...they are taught from Day #1 of medical school that death is a failure, even when it's the best option for the patient. Best of luck to you.

[sassysteph7]

thank you for all the replies. I guess I didn't say anything to the patient because I felt doing so was futile. why would it be futile you ask? It would have been so because the patient's mother did not want him to be a DNR. In my short ICU experience (only started in August 09) I've seen family members go against their dying loved one's wishes and the dr's go along with it. It makes me scared for the day I'm dying and my wishes are not respected.

Oh and how can I be charged with assault if the patient does't want cpr but his mother says for me to do it after he's coding? I know he's 42 but dr's don't listen to their patients alot of times. They are so afraid of being sued that they listen to the families more so than the patient's actual wishes.

[TemperStripe]

Sounds like a family meeting is in order...

[PMFB-RN, RN]

I've seen family members go against their dying loved one's wishes and the dr's go along with it.

*** What did you, the patients advocate do to protect your patient's wishes in that situation?

Oh and how can I be charged with assault if the patient doesn't want cpr but his mother says for me to do it after he's coding?

*** Well that depends. If the patients doesn't make it then no worries. If he does and he had previously made his wishes clear then it is possible he could have those who participated charged. I have never seen it happen but was told about the potential at an ethics conference.

I know he's 42 but dr's don't listen to their patients alot of times. They are so afraid of being sued that they listen to the families more so than the patient's actual wishes

*** I make sure my patients wishes are known to the physicians, loudly if necessary and I will (and have) made calls to the chair of the ethics committee, the chief of staff, the patient advocate, nursing supervisor and our hospital's risk manager (a lawyer) in the middle of the night when required.

[tri-rn]

"Do Not Resuscitate" does NOT mean "Do not intubate". Did he ever say he didn't want to be intubated? Did anyone actually code him? The fact that his doctor "revoked" his DNR status (not sure how he could do that, but I guess anything is possible) would have no effect on his being pre-emptively intubated to AVOID a code.

These situations are frustrating and disheartening, I feel your pain and am NOT being critical. It sounds like you wanted your patients wishes to be respected . For us to respect patients' wishes, we have to very clear as to what those wishes are.

We had a 40-something pt once who wanted to be a DNR, the team ordered a psych eval. While patients certainly have a right to have thier wishes respected, the psych eval was sort of understandable, given that the guy wasn't terribly sick (there were other issues too, including a mental health hx). It turned out that he "didn't want to be kept alive by machines if I'm a vegetable". No one had ever clarified for him what "DNR" actually means.