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?
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 ...
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 ...
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 ...
Using your logic, a living will means nothing. Then why are we spending so much time asking patients if they have one, making sure a copy is on the chart, and making multiple copies to hand out to all involved in that patients care? Why is this a JCAHO standard?
This is the exact situation that a living will is created for. Fear of a lawsuit should NOT violate that patients right to have her wishes carried out. The hospital is legally covered by that living will.
Using your logic, a living will means nothing. Then why are we spending so much time asking patients if they have one, making sure a copy is on the chart, and making multiple copies to hand out to all involved in that patients care? Why is this a JCAHO standard?
This is the exact situation that a living will is created for. Fear of a lawsuit should NOT violate that patients right to have her wishes carried out. The hospital is legally covered by that living will.
I don't disagree with you at all -- I'm just telling you how the reality usually works out in this sort of circumstance, unfortunately ...
JCAHO? Oh, please. They create standards to justify their own existence. and to justify charging hospitals a fortune to get surveyed -- many of their requirements have little or no relation to everyday life in hospitals ...
I don't disagree with you at all -- I'm just telling you how the reality usually works out in this sort of circumstance, unfortunately ...
I know it happens, been doing this for 24 years, and it makes me SO angry that we have this whole system in place for someone to die with dignity, and then lawyers opinions violate that wish.
Specializes in icu, er, transplant, case management, ps.
I have had a Living Will for more then twenty years. But more important, my daughter is my first health care proxy. And my older brother, in case she cannot serve. This is where I believe your problem lies. The patient has a Living Will but no one has been appointed her health care proxy. No one can say comply with her wishes for a DNR or else. Unfortunately, most older people do not have a health care proxy. And when families are confronted with the person's imminent demise, an argument ensues.
It is kind of late to be worry about not following her initial wish. She has been 'saved' several times already. I am not an attorney but was once a hospital administrator. And I would continue to code her until she dies or the family wakes up and complies with her directions. And I believe a hospital attorney would agree with me.
I don't know how many times I have advised others to:
1. Have a Living Will.
2. Have a health care proxy.
3. Be clear, on both just what you wish and do not wish to be done.
4. Make sure you talk with your doctor, provide him with copies of both and he agrees with you.
This takes the responsibility a way from your nurses, physicians, hospital. And puts it squarely on your health care proxy. Be sure that your health care proxy agrees with you. If you are not certain, do what I did. I have threatened to come back and haunt my daughter and brother, if they fail to follow my wishes.
I know it happens, been doing this for 24 years, and it makes me SO angry that we have this whole system in place for someone to die with dignity, and then lawyers opinions violate that wish.
Lawyers? Families.
The difference between a living will and DNR is clear, BTW. One is not the other.
Having a living will, or Advanced Directives on the chart is not enforced until the physician actually writes the order for DNR, or whatever else. You need a physcian's order not to code the patient, and until one is written, the patient needs to be coded.
This is what the patient wishes, but only that, it is not a written order. And that is what you need to adhere to.
Shame when families fight over the loved-ones like this, but see it happen all of the time.
Hope that ethics and risk management get it sorted out sooner rather than later.
If the doctor hasn't written an order stating the pt. is a DNR then she will need to be coded.
I understand the pt. has a DNR/Living will from 5 years ago, but that is an out of hospital DNR.
Also, those papers will have needed to be placed on the chart and co-signed during the current hospitalization to make them a legally binding contract. A lot of things could have changed in those 5 years since that was made.
elkpark
14,633 Posts
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 ...
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 ...