so this situation is over and done with, but it's weighing heavily on my mind. i would like any input on what you guys think....
i had a patient last night with metastatic CA (originating in the bladder) who was on home hospice care. apparently he was admitted the night before with a bowel impaction, was disimpacted and was being given IV hydration for comfort before being sent back home with hospice.
the patient had signed a refusal of treatment form to say that he did not want CPR or intubation should his heart stop. day shift nurse passes on to me in report that we still need to obtain the physician's signature on the paperwork and a written order to honor the DNR. i spoke with my charge nurse at the beginning of the shift and she said we cannot honor the DNR that he signed without the doctor's order, she said we can call in the morning, he is stable and has no changes (our charge calls docs for night shift--and it has to be a supervisor plus 2 RN's to take any DNR order over the phone). i thought if a refusal of treatment was signed for anything, it meant don't do it, right?
pt was AAOx3 for the time i had him, got scheduled tramadol and one dose of 2mg dilaudid. vital signs were stable except he flip flopped being tachy-brady, which was no change since his admission the night before. at around 2:30am, the monitor tech calls to say he bradyed down to 47 and tached back up to 140 and back down again, just wanted me to be aware it was more frequent now. i went to check the patient, he was resting quietly and still breathing. i called the nursing supervisor to ask the what if question of what this man goes into an arrest, do we really need to code him? she said yes. i wanted him to go in peace if it was his time. his wishes were made clear by him and he was supposedly a hospice patient at home.
at 3am, the pt went into a 3rd degree AVB. i went to check the patient again and saw he was taking agonal gasps. his color had changed to very dusky and he had a very weak pulse. he was hardly perfusing. so with a very heavy hand, i pressed the code button and stood there like a dummy. i didn't want to start CPR, i didn't want to open his airway, i wanted to hold his hand and honor his wishes. i waited as the team arrived with the ER doc and i explained the situation to them. the ER doc was kind of just as perplexed as i was about the whole thing but he said i did the right thing in calling the code, he said he really needs the approval of the primary MD to terminate ACLS.
so here we are, code in progress on a supposed hospice patient with DNR wishes and metastatic CA. CPR in progress, i finally after 3 attempts and 10 minutes later, got a hold of the primary who spoke with the ER doc and told him to cease the code blue. where was the hospice paperwork? why didnt the doctor write a DNR under his admitting orders?
i was really in tears at this point. everyone kept saying i did the right thing. i don't feel like i did. i did what my supervisors told me was legally correct, with their stance being that the family could come back and say the pt was not AAOx3 at the time when the refusal of treatment paperwork was signed.... but the patient was on hospice care at home! is hospice rescinded or something if the patient gets admitted to an acute care area???
legally correct, yes. morally correct, no. i feel like the man was assaulted and battered and that we did not honor his wishes just cover our own tails. the man was suffering and in pain and wanted to die naturally. we did not intubate or defibrillate, and he only had one round of meds, as the ER doc was conservative in treatment bc of the situation.
i feel awful about it. why so many technicalities for this poor man? where did the line get drawn or the ball get dropped or whatever? why isn't a refusal of treatment good enough? and what's the deal with hospice pts in acute care? i am so confused. i feel like it was a code that never should have happened.
