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Discussion

Full code when living will is on chart?

Here's the situation; LOL transfered to our unit from CICU. She was found down and unresponsive, brought to ER by one of the adult children who said Mom was a full code. Brought back once in ER, codes 3 more times in CICU, and is finally in our stepdown unit. She's breathing on her own, but basically, all her other brain functions are practically non-existant, and she's so fragile I'm afraid if I sneeze in the room, she'll code again. Also on contact precautions for MRSA, has mets colon ca, and the crappiest strips any of us have ever seen outside a ACLS class. She gets to our unit, and Surprise! mom had signed a DNR/living will 5 years ago. Now we've got someone we've (the hospital, anyway) has brought back 4 times, and we're all in circles about what to do when she codes again. If we bring her back, we're violating the DNR. If we don't, and the hospital has already established a pattern of bringing this LOL back, could we get in more trouble for bringing her back, or not bringing her back? The doc says the siblings are all fight over whether or not to bring mom back, and therefore, if they can't reach a concensus, we treat her as a full code (if she's a DNR and was legally able to execute a DNR at the time, then why do we need a "concensus?!") This wonderfully concerned family hasn't called the unit to check on mom, visit mom, etc., for the last 3 days. Any ideas/similar circumstances out there?:banghead:

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In NYS a DNR is issued every single time a patient comes in.

I'm not a lawyer but I'd sure be bringing her back if the kids are fighting over it.

DNR is an order on the chart, from the physician, for this hospitalization.

Living will states that if these certain conditions are met, and my doctor believes I am terminal, etc, I do not want heroics, life support, feeding tube, blah, blah, blah. They can say all sorts of different things. I read one once that said, "if I'm brain-dead, I do not want to be kept alive." Well, duh, we don't keep people alive once they are declared brain-dead, unless they are an organ donor to harvest the organs.

I'm a young woman with no medical problems and I have a living will. But if I go into the hospital tomorrow, I'll be a full code. If I had terminal cancer, that might change, but I'd cross that bridge when I came to it.

Was the patient from a nursing home? Was she a DNR there? In some states and at some facilities, it can carry over from one facility to another. You have to know the law for your state and the policy for your institution.

  • Experts

This is why every hospital pays big bucks for legal counsel -- this is the sort of situation in which their advice would be v. helpful. Has anyone asked them?

  • Author

Went out and read our state's rules on Living Wills. In our state, they are a legally binding document (I think in some states they aren't, just an actual DNR order is). Our charge was going to bring it up to our NM and get legal's opinion, but from what I've heard about past situations, they make up their minds slowly. I can just see me going in tomorrow, our lady coding, and me looking at the big button, wondering if I should hit it or not...

She came from home, so we don't have a NH record to fall back on. It's just a mess

Went out and read our state's rules on Living Wills. In our state, they are a legally binding document (I think in some states they aren't, just an actual DNR order is). Our charge was going to bring it up to our NM and get legal's opinion, but from what I've heard about past situations, they make up their minds slowly. I can just see me going in tomorrow, our lady coding, and me looking at the big button, wondering if I should hit it or not...

If you don't hit it your rear is going to be in a huge sling and the facility will throw you right under that big bus of a lawsuit coming from the rotten kids.

Went out and read our state's rules on Living Wills. In our state, they are a legally binding document (I think in some states they aren't, just an actual DNR order is). Our charge was going to bring it up to our NM and get legal's opinion, but from what I've heard about past situations, they make up their minds slowly. I can just see me going in tomorrow, our lady coding, and me looking at the big button, wondering if I should hit it or not...

If her attending is available and approachable when you get there, I'd nab him/her as soon as you can and ask what you should do in that instance. Their opinion may not be as good as your legal dept's, but at least you'd have documentation that you didn't make the decision on your own, should it come to trouble.

HIT THE BUTTON

it could be a a lawsuit if the children are disagreeing on this, some states have a time limit on dnr/living will, the most important thing that you possess is your license..i would hate to code someone against their will but this is a decision that you can and should pass the buck about

I would call a code to cover my behind. You worked to hard in nursing school to put your license on the line. Not to mention the long nights of studying, blood, sweat, and tears over getting your license. No one is worth putting your self and hard work in jeopardy.

Patient isn't going to survive many more codes if any.

DNR is a doctor's order.

Ethics should be involved. The patient clearly stated their wishes and whoever the advocate is should be making decisions. If they call full code, full code it is. The family battle should be covered by the living will and the advocate.

Normally, the doctor takes care of this. Some are better than others at resolving it.

Has ethics been called?

  • Author

I appreciate all the help. What I'll do when I go in is find out if we've got any response from legal, if ethics committee is involved, and if the doc has got his "concensus". I guess he's seeing the lawsuit bus too, and trying to keep everyone happy. I'll code her, but I'll feel conflicted about it....poor little thing, I read her living will, and we're doing exactly what she was afraid of.

The whole point of a living will is to make the PATIENTS wishes known should they be unable to communicate that information. The kids are out of it once the living will is on the chart and if none of them are named as the health care proxy. If someone coded a member of my family when there was a living will on the chart I would NOT be happy.

If families are allowed to overrule the living will there is no reason for anyone to do a living will. A living will is a legally binding document of the patients wishes. No one else has the authority to change that.

The doctor should be reviewing the LW and writing the DNR, end of case.

Get eithics involved. If the hospital had her living will and still coded her 4 times they are in a very tenous legal situation.

I would not be taking care of this patient until there is a legal decision and I sure wouldn't code someone with a legal living will.

  • Experts
The whole point of a living will is to make the PATIENTS wishes known should they be unable to communicate that information. The kids are out of it once the living will is on the chart and if none of them are named as the health care proxy. If someone coded a member of my family when there was a living will on the chart I would NOT be happy.

If families are allowed to overrule the living will there is no reason for anyone to do a living will. A living will is a legally binding document of the patients wishes. No one else has the authority to change that.

The doctor should be reviewing the LW and writing the DNR, end of case.

Get eithics involved. If the hospital had her living will and still coded her 4 times they are in a very tenous legal situation.

I would not be taking care of this patient until there is a legal decision and I sure wouldn't code someone with a legal living will.

I have seen plenty of situations where a client's previously expressed (and legally documented) wishes were overruled by family members at the bedside who wanted "everything done" and Mom or Dad kept alive, no matter what. Hospital attorneys have explained to me that the reasoning is quite simple -- hospitals hardly ever get sued for coding someone who didn't want to be coded, but they get sued all the time by family members who wanted their loved one kept alive. For people responsible for looking out for the hospital's best interests, the math is pretty simple ... :rolleyes:

The reality of this situation is that no one (no one in any condition to make a fuss, that is -- sounds like the client isn't going to be sitting up in bed and 'phoning a lawyer) is going to be mad at the hospital for having coded her. It's naive to think that the client's wishes are going to be honored over those of the family members in this situation, "legal" or not ...

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