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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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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.

  • Experts
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.

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.

Woody:yeah:

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.

  • Experts

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.

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