ethical dilemma with a DNR last night

  1. 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.

    ugh.
    i need to go to sleep.
  2. Visit flightnurse2b profile page

    About flightnurse2b

    Joined: Jul '07; Posts: 2,287; Likes: 4,696
    Paramedic/LPN; from US
    Specialty: EMS, ER, GI, PCU/Telemetry

    41 Comments

  3. by   Kyrshamarks
    In Texas a pt or family can sign their own DNR and it is valid even if the doc does not sign it.
  4. by   CrunchRN
    Just pitiful. Who the heck is the doc to be the only one that can authorize it when the patient has chosen and this is known. Makes me sick.

    You did what you had to and are an awesome nurse i can tell, but i find it just revolting when a person makes a decision and it is known and then some technical BS says that only the doc can validate it? Hope no one ever pulls that one on me cause if I live I might just kill them!
  5. by   The Hated Consultant
    Unfortunately our society today is so litigious, you have to CYA at all times.

    It sucks and it's stupid, but you did what you had to do. I agree that this man was assaulted and HIS wishes had to be put aside, but it's because of that aforementioned litigiousness.

    I'm so sorry you had to go through that.
  6. by   brighella
    Something that happens here which might help explain a little bit, is that when patients are admitted to an acute care hospital, unless its the one that the hospice has a contract with, that patient will actually be taken off of hospice service for the duration of the admission. My understanding is that it has a lot to do with billing. Pretty sad that money and fear of being sued trumped the patient's wishes...
  7. by   ghillbert
    Sounds like you did what you had to since you'd been instructed to by your charge. Sometimes it's better not to ask... I think I would have walked to that room verrrrrrrrry slowly when I heard about the AVB. Poor man. Hope you can do something about your workplace's processes so it doesn't happen again - very hard for you.
  8. by   canoehead
    If you get an order to dc the moniter then you will discover most patients long after they are aware of any interventions. If the patient was "stable" he doesn't need a moniter, right?

    I would have a huge problem with working somewhere if I could not call the physician when I felt it necessary. It's my butt, and my judgement that comes into question, so I want to be able to communicate freely with the physician about my concerns.
  9. by   MagicAvalon
    You are that patients assigned nurse, charge nurse or not I would have called the MD as soon as I took the assignment. Since when is it a charge nurses decision, that is up to the MD. Poor decision if you ask me, Yes, I am a charge RN. You know what hits the fan when things happen... it's not the charge that takes the hit.. it's YOU, the assigned nurse !! CYA !!!
  10. by   sasha2lady
    I work in LTC and we cant honor DNR's til its signed and written by the MD either. We get tons of admissions who come in with signed DNRs from the hospital that we cant honor.....its a big mess. I had a pt with lung ca..mets all over her body and brain...she had 5 kids and they argued all the time about a DNR. One dtr said to me that if we turned on the radio in her room that it would shrink her brain tumors....she was crazy and in denial. I finally got the main daughter to sign a DNR sheet a few days before she died. Our MD told the family that for them to want to kep this woman alive was cruel and inhumane and no amount of tubes or resusitation would save her.....I just knew she was going to code on my shift. This topic is always a touchy subject for alot of families and some pts.
  11. by   blondy2061h
    1 fingered CPR for the win!
  12. by   Mrs.Rollins
    I agree with MagicAvalon on this one. You're a compassionate and caring nurse: let this experience influence you in the future. Next time, make the call. If your charge gets ruffled that's okay; at least you'll never have to go home feeling this way again.Take care.
  13. by   leslie :-D
    well, you know what allie?
    thank goodness he died.

    imagine if he survived the code.

    if someone's hospice benefits are revoked r/t inpt hospitalization, it probably wouldn't be a bad idea to hunt the doctor down...
    and in the meantime, slow down the code.

    it's all good now.
    get some rest, honey.:icon_hug:

    leslie
  14. by   kanzi monkey
    I definitely would have taken the monitor off this patient. While he may, legally, be a "code", the only purpose the monitor could serve would be TO CODE the patient. Even if you still need the attending's order for DNR/DNI, the hospice plan shouldn't change for this patient (that is, comfort measures--you are not trying keep this man alive), and telemetry doesn't fit with that.

    That being said, you did a great job. It really frustrates me that end of life issues become obfuscated in the realm of acute care--yes, patients become critically ill before they die. To reverse their code status--or at least, to not communicate every element of care (from monitoring to treatment) to the patient or the proxy is ludicrous. And suddenly, right at the moment of your death, you have a whole bunch of strangers running around you thinking about saving their own behinds and whether or not they're going to get sued.

    It is unintelligent.

close