Fickle DNR question

[Lohen90]

So my worst nightmare happened to me today. And this is long. I had a 70 year old man with end stage COPD. He was barrel chested, anxious, had substernal retractions. He was cachectic. He was satting well (89-92%) on 3L nasal cannula. He was a DNR. He had recently been intubated and on the med surg floor after a successful extubation. He had to be tubed when his wife found him unresponsive. He also had MRSA pneumonia and he said this was the the 10th time this year he'd had it. He was alert and oriented and when I was taking to him I realized he didn't know what a DNR meant. I explained it to him. He said he didn't want it and wanted to be intubated if something bad were to happen (again). I said ok. Called the doc and told her and made him a full code. Mind you he had already signed up for hospice.

So later on the NP and wife come in. I let the NP know he's rescinded the DNR. The wife freaked out. She said "honey we talked about this, you're end stage, I can't keep going through this" the NP re-explained his condition to him, how intubating him was futile and wouldn't cure his condition but only prolong the inevitable. He agreed to be a DNR once again. His wife also basically told him she would make him a DNR anyways once he was unconscious again, so he really didn't have a choice. He also said he would feel bad if she had to make the decision to stop life support. The DNR is signed everyone seems to be on the same page and happy. We're waiting for hospice to come evaluate him.

About an an hour later he is eating and has a panic attack because he feels short of breath. His sats are low (82%) and he keeps saying "I need air". I bump him up 1 L and ask him to take deep breaths and stop eating and catch his breath. He does, sats come up (98%), I bump him back down. Another hour later (with wife still at bedside) he starts panicking again, he said he needs more air. I check him again, he's satting well but tachypneic and we get him to calm down. He ask for something for anxiety. I offer him either Ativan 1 mg IV or morphine. He and the wife opt for Ativan. So I give it. He was talking to his wife about an hour later and became tired, so she left.

2 hours later I check him and he's still sleeping. He's also not rousable. However his vitals are perfect. He was actually satting 99% on two Liters. I try everything I know how to wake him up. He's not waking up but again vitals couldn't be better. I check sugar & it's 168. Call the doc and let her know. Also hospice comes in and I ask if he would qualify for the hospice house (inpatient hospice) and she says yes she can get him in tonight. She calls the wife and lets her know. Doc signs DC orders and the wife comes in as were arranging transport. Then the wife sees him and loses her mind. She says this isn't him and he needs to come back to her. She blames me and asks me what I gave him. I show her the MAR. The only thing he had all day was one mg IV Ativan while she was present. She says Ativan isn't good for him and not to give anymore (of course). By this time it's been seven hours since I gave it. I explain it doesn't last this long IV normally but he is probably having trouble clearing it from his system since he is so chronically ill. She wants a reversal agent and asks if it will wear off and he'll be back to normal. Mind you he had just been extubated in ICU 2 days prior. This is the same woman who wanted the DNR. The same women who discussed hospice today. Who told him this was the end. The same woman who requested I give the Ativan earlier. The one who was aware he was going to the hospice house that night. She didn't rescind the DNR but this was the end of my shift. I gave report and left. I wrote a long note about the days events. I'm still getting whiplash from the change of hearts between the two of them. She seemed so sure it was his time just that morning. What happened? Did I do something wrong? I had him hooked up to continuous vitals all day. Checked on him frequently and did what they asked to keep him comfortable but stable. He still had perfect vitals when I left. I used to work a hospice floor and have never had someone so sure of what they wanted change their mind like this before. Im actually kind of scared to have another DNR COPD patient again...ill certainly be very wary of giving Ativan to anyone for a while.

[EDNURSE20, BSN]

You did nothing wrong. Neither did the pt and his wife. They going threw a major loss, that's hard to accept. They are going to be all over the place. When he is up and at his best it would of been easier to discuss the DNR, than actually seeing him unresponsive and thinking that this may be it.

In times like these you need to do you best to support the family, and understand that they aren't thinking/acting rationally. We understand what's going on and feel comfortable in the hospital, but they don't. This is all new to them, let them do what they need to cope with it all.

[DextersDisciple, BSN, RN]

Honestly if hospice was already consulted I wouldn't have asked the dr to change the code status but instead asked him/her come evaluate and answer any concerns the pt has themselves. It shouldn't have been that easy for the dr to change code status In a single phone call. Look at the patient! (Pet peeve of mine)

You did nothing wrong by giving him Ativan- you did what was appropriate for a hospice pt, making them comfortable. Hopefully there is an advanced directive/living will so she can't just keep changing her mind based on minute by minute emotions.

[Davey Do]

Welcome to AN.com, Lohen!

Outstanding nursing care and communication... if your professional documentation is anything like your first post, I believe you have adequately CYA!

The very best to you!

[JKL33]

It sounds like you provided great care. You can rest easy about that, and don't fear what situations will crop up in the future - and they will. These scenarios like what you experienced today are very common. What you'll do next time is the same thing you did this time - take each minute or hour one at a time and make sensible nursing decisions as the need arises. :) You did great.

Off-topic, I'm sure you know this, but:

His wife also basically told him she would make him a DNR anyways once he was unconscious again, so he really didn't have a choice.

That is most definitely NOT how that whole deal is supposed to work. When a patient can make his/her own wishes known and is judged to have the capacity to make that decision, it is supposed to be honored to the extent reasonable for the situation. The role of the NOK isn't to reverse the patient's decision once the patient becomes unconscious. If there is a known disagreement (such as, if this patient had persisted in wanting to be full code) it needs to be addressed right then; ASAP. I would've been sensitive/careful, but I probably would've gently explained to his wife right then that it doesn't work that way, so it's important that we talk things through (with hopes of coming to a consensus....). She does sound like she was (reasonably) grieving the whole situation and very stressed. A care conference or SW consult (etc) can help with situations like this.