Full Code By Default- TBD

[bmont96, BSN, RN]

Hi everyone,

Just needed a little advice and reassurance on something that happened a few days ago. I'm an RN on a telemetry unit and I admitted a patient with syncope, super stable. About 5 hours into shift, she went into Vtach, and code blue was called. Team arrives, resuscitates her within 4 minutes. She was transferred to ICU on Bipap and back to her normal baseline neuro status (aXoX1). Code status was full code by default. Turns out, she had a POLST from last year, stating DNR/DNI with selective treatment. Code status was not updated. I have been experiencing extreme guilt and sadness over this, and am terrified for my job. Charge nurse reamed me, stating I should have looked for a POLST. I Other team members said they would have done same thing as I would have. Incident report was filed. 

Has anyone else been in this situation? 

[JBMmom, MSN, NP]

There's absolutely no reason for a default code status in a patient that is alert and oriented on admission. I think that this falls largely on the admitting provider. I know that in my job as a NP doing admissions, I consider clarifying code status to be one of the most important parts of my admission process. This patient, being super stable, would have been able to tell the admitting provider of her wishes and then it would have been clarified before it got to you.

I admit that in my bedside RN role, it's also one of the first questions I ask when I'm admitting a patient, so I can either confirm the code status entered by the provider, or clarify the patient's wishes. I wouldn't put the blame squarely on you, but since you say that you admitted that patient, I would just make it a practice in the future to ask patients yourself on admission so you're not left in this position again.

Sounds like the patient ended up being okay, so I don't think you need to worry about your job. If she was injured in the resuscitation there could have been more serious outcomes. On a busy floor assignment, expecting everyone to dig through the chart for stuff isn't necessarily realistic, but we should all clarify our patient's wishes in our job as patient advocates. Don't beat yourself up. 

[bmont96, BSN, RN]

4 minutes ago, JBMmom said:

There's absolutely no reason for a default code status in a patient that is alert and oriented on admission. I think that this falls largely on the admitting provider. I know that in my job as a NP doing admissions, I consider clarifying code status to be one of the most important parts of my admission process. This patient, being super stable, would have been able to tell the admitting provider of her wishes and then it would have been clarified before it got to you.

I admit that in my bedside RN role, it's also one of the first questions I ask when I'm admitting a patient, so I can either confirm the code status entered by the provider, or clarify the patient's wishes. I wouldn't put the blame squarely on you, but since you say that you admitted that patient, I would just make it a practice in the future to ask patients yourself on admission so you're not left in this position again.

Sounds like the patient ended up being okay, so I don't think you need to worry about your job. If she was injured in the resuscitation there could have been more serious outcomes. On a busy floor assignment, expecting everyone to dig through the chart for stuff isn't necessarily realistic, but we should all clarify our patient's wishes in our job as patient advocates. Don't beat yourself up. 

Patient was AxOx1 on arrival, her baseline. She was unable to answer any of my questions. 

 

But yes absolutely, I will definetly clarify this first for all future patients. 

[JBMmom, MSN, NP]

1 minute ago, bmont96 said:

Patient was AxOx1 on arrival! That's her baseline, son was POA. 

Sorry I read that wrong. I saw the stable part and my brain read A&Ox4, oops. The admitting provider should have reached out to the POA to clarify then. Shouldn't fall on you.

[sleepwalker, MSN, NP]

On 9/3/2022 at 7:13 PM, bmont96 said:

Turns out, she had a POLST from last year, stating DNR/DNI with selective treatment. Code status was not updated.

Sounds like an active POLST was in place...who's responsibility is it to verify the code status on admission and ensure that the pt is properly identified?

[MaxAttack, BSN, RN]

I've never seen my unit automatically honor a prior DNR. It could have been more than a year since the last admission or they could have been to different outside facilities. How do we know those are the patient's current wishes unless it's clarified either with the patient or a proxy/surrogate?

Don't feel bad. It's a busy job and we don't always have time for these things. I always err on the side of keeping someone alive - you can always withdraw. It's much harder to bring someone back from the dead. Live and learn.