Revived when there was a DNR/AND code status

[ambersky004]

There was this experience that I will never forget in my nursing career.

Patient N came back with Afib with RVR. She converted to SR during shift change. The night nurse said she had episodes of chest pain. From her report she said the Pt N was more anxious that night. Pt N told the attending doc she wanted to go home and if she die of a heart attack she is fine with it. Her code status was DNR/AND. The heart doc said she needs stress test or cardiac cath but she's been refusing the cath the last time she was in our unit. I told the hospitalist she has been talking about her dead sister this morning and she wanted to "visit her?" She was teary-eyed. She denies any chest pain except last night. She denies any depression or thoughts of suicide to the attending doc.

So the attending doc told her the plan is she can go home with an outpatient stress test. Her 3 Troponins where elevated but trending down. Her series EKGs shows she had a previous MI and afib. WHile I was discharging another patient and educating her family and answering there questions, I saw our CNA wheeling our crash cart. So I look where he is going and I saw staff in a room. It is weird I did not hear the rapid response called. So I went and saw the RT doing CPR and ambu bagging. Our on call doc was in room and I told him she is a DNR. I saw the V-fib on the heart monitor and the heart doc asked me a question and told him she came in with Afib RVR. He asked me who is the doc I told him the heart doc but forgot she was not on duty that day so he said to call her and asked what she wanted to do.

So I called her and she said she will be right there. When I came back pt's attending doc was in there now and told them and the on call heart doc she is a DNR but she was defibrillated anyway or they still defibrillate her. The patient woke up and was a little upset, she was telling me, "that was my time." Or maybe because she fell unconscious and she might still be in a fog. I feel so guilty. I felt like i missed something like putting the DNR armband. Maybe that would change the doc's and team members intervention since I was not there immediately in the room. I swear i did not hear the overhead call. The attending doc was telling me, she's going to be pissed. So I scratch my head and the heart doc laughed at me, I think 'coz he looked me in the face but i was so shooked up it happened so fast 'coz the attending doc just talked to her that time and I just rounded her. Lastly, the patient is alive and agreed to get a cardiac cath.

In regards to ethical issue and patient's wish during hospital stay, did we break her code status? Will there be an issue? I always thought that atleast try to revive the patient when there is a chance. And probably that was the heart doc's thinking but the attending doc was on the patient's side. Ughhhh. What should I do the next time i encounter this situation? I know the patient is well-knowledgeable of her condition and her risks.

[Tenebrae, BSN, RN]

I'm aware that due to my own personal biases I may be projecting a little here.

My brother in law just died from pancreatic cancer and my mum has terminal lung cancer. She has made her wishes known to us kids, and has an advanced directive on file.

If a health care team over-rid that and proceeded ignore that and to resuscitate her I would be beyond next level angry and out to make sure heads roll. All that would happen is her ribs would break due to bony mets and if she was successfully bought back would be in even more pain than she is now

To prevent this happening again I suggest you become very familiar on the policy regarding patients who are DNR and what needs to be done to ensure that all member of the healthcare team know the patients resus status and this doesn't happen again

The patient didn't want to be resuscitated. The doctors and the medical team thought they knew better and her resus status wasnt communicated properly. Sorry I dont have anything reassuring to say.

[Here.I.Stand, BSN, RN]

(((Hugs))) Tenebrae

[ambersky004, BSN, RN]

I would let risk management know, document you advised against cardioversion in the code sheet, and request a debriefing of the code. Doing a root cause analysis of how the code status was disregarded (without pointing fingers) can keep it from happening again.

We are human, we make mistakes, this is why healthcare will never be perfect. Most doctors, when unsure, would rather get reprimanded for saving a patient who didn't want to be, than failing to save someone who did (or who's family did).

I've worked at a lot of places who put a laminated heart or some other sign on the door and over the bed that visitors won't recognise but the staff knows means the pt is an AND. We also don't usually have them on monitors. If they are a partial code there is a neon binder at the foot of the bed (you can't miss it) with the advance directives.

But our code status's get overturned a lot in PICU, parents think they have made their decision until their child is actually actively dying, when they see them lose consciousness, they change their minds a lot. All it takes is a verbal retraction and }POOF{ get the crash cart.

I've never been in a situation where a pedi patient was revived against the family's

wishes.... all the signage is mostly to keep out unnecessary staff to give the family privacy.[/quote

[ambersky004, BSN, RN]

I would let risk management know, document you advised against cardioversion in the code sheet, and request a debriefing of the code. Doing a root cause analysis of how the code status was disregarded (without pointing fingers) can keep it from happening again.

We are human, we make mistakes, this is why healthcare will never be perfect. Most doctors, when unsure, would rather get reprimanded for saving a patient who didn't want to be, than failing to save someone who did (or who's family did).

I've worked at a lot of places who put a laminated heart or some other sign on the door and over the bed that visitors won't recognise but the staff knows means the pt is an AND. We also don't usually have them on monitors. If they are a partial code there is a neon binder at the foot of the bed (you can't miss it) with the advance directives.

But our code status's get overturned a lot in PICU, parents think they have made their decision until their child is actually actively dying, when they see them lose consciousness, they change their minds a lot. All it takes is a verbal retraction and }POOF{ get the crash cart.

I've never been in a situation where a pedi patient was revived against the family's wishes.... all the signage is mostly to keep out unnecessary staff to give the family privacy.

On initial admission, if the patient has a AND code status, we should put a blue bracelet on the pt.

[ambersky004, BSN, RN]

nursing school is going to do a great job of teaching you how to pass the NCLEX. The official answer is she didn't leave the room, use the bathroom, eat breakfast, administer medications, attend to her hypoglycemic patient, or reconnect a patient's circuit who's vent was alarming before she documented everything exactly the way it happened as if God himself had been in the room.

After you pass NCLEX the answer is: patient care always comes before documentation. If you can document in real time, DO IT, but odds are your assignment is rarely going to allow you to.

Yep, so much in my hands that day. The only thing I was upset about is that they did not listen to me when I was the patient's nurse, they did not even listen to the attending doctor who was also in the room. The problem was the nurse and the nursing supervisor activated the code without notifying me first when they saw the V-fib on the monitor. I told the doc she is a DNR, when the attending doc came in that was what she told too to them but the heart doc who was part of the code team decided to defribrillate her once and that's it she was brought back. I let the nurse document that she activated the code. I made a late entry below her documentation of what had happened.

[ambersky004, BSN, RN]

There are times where we cannot chart right then immediately but on something so serious especially, I would have stayed over and not left without some good CYA charting.

I know, i was focus on my next admit and its documentation. I told the nurse who activated the rapid response to document what she did. But i forget to make my own note. I did make a late entry note after 5 days.

[ambersky004, BSN, RN]

What have I learned are 1. I know i failed the patient 2. I should have documented the event. 3. I shouldn't point fingers because I know everyone in that room does not know her code status until I came in and told them she is a DNR/AND. 4. You have to listen. I wonder why the heart doc continue to defibrillate her when the patient's hospitalist already informed them that she is a DNR/AND. 5. Always cover your butt. 6. Always stay kind and listen to what they say. I build rapport to this patient since I took care of her twice. I told her that I was sorry. And to think that day she suppose to be discharged to home and will drive herself back home.

[Crush]

What have I learned are 1. I know i failed the patient 2. I should have documented the event. 3. I shouldn't point fingers because I know everyone in that room does not know her code status until I came in and told them she is a DNR/AND. 4. You have to listen. I wonder why the heart doc continue to defibrillate her when the patient's hospitalist already informed them that she is a DNR/AND. 5. Always cover your butt. 6. Always stay kind and listen to what they say. I build rapport to this patient since I took care of her twice. I told her that I was sorry. And to think that day she suppose to be discharged to home and will drive herself back home.

I don't think you failed the person. You said you let the code team know the person was DNR. The only criticism would be about not documenting that day before you left. In the end, it is easy for me to sit here and say what could have/should happened after the fact. However, during the event I am sure you did the best you could with what you knew then and what was available then. This is where a good debriefing afterwards comes in handy. It is where all who were involved can look at the event in hindsight and discuss ways to improve should this situation happen again. And yes, #5 is so important. Best wishes and be gentle with yourself. Use it as a learning experience. No matter how long anyone has been a nurse, we can and will continue to learn and grow.

[ambersky004, BSN, RN]

I don't think you failed the person. You said you let the code team know the person was DNR. The only criticism would be about not documenting that day before you left. In the end, it is easy for me to sit here and say what could have/should happened after the fact. However, during the event I am sure you did the best you could with what you knew then and what was available then. This is where a good debriefing afterwards comes in handy. It is where all who were involved can look at the event in hindsight and discuss ways to improve should this situation happen again. And yes, #5 is so important. Best wishes and be gentle with yourself. Use it as a learning experience. No matter how long anyone has been a nurse, we can and will continue to learn and grow.

Thank You for your kind words. I am trying to be gentle with myself.

[Farawyn]

nursing school is going to do a great job of teaching you how to pass the NCLEX. The official answer is she didn't leave the room, use the bathroom, eat breakfast, administer medications, attend to her hypoglycemic patient, or reconnect a patient's circuit who's vent was alarming before she documented everything exactly the way it happened as if God himself had been in the room.

After you pass NCLEX the answer is: patient care always comes before documentation. If you can document in real time, DO IT, but odds are your assignment is rarely going to allow you to.

Nah. Something like this? I would have stayed and covered my ass.

Something ACTUAL nursing taught me.

[Farawyn]

I'm aware that due to my own personal biases I may be projecting a little here.

My brother in law just died from pancreatic cancer and my mum has terminal lung cancer. She has made her wishes known to us kids, and has an advanced directive on file.

If a health care team over-rid that and proceeded ignore that and to resuscitate her I would be beyond next level angry and out to make sure heads roll. All that would happen is her ribs would break due to bony mets and if she was successfully bought back would be in even more pain than she is now

To prevent this happening again I suggest you become very familiar on the policy regarding patients who are DNR and what needs to be done to ensure that all member of the healthcare team know the patients resus status and this doesn't happen again

The patient didn't want to be resuscitated. The doctors and the medical team thought they knew better and her resus status wasnt communicated properly. Sorry I dont have anything reassuring to say.

I'm so sorry for your recent losses, Ten.

[Julius Seizure]

On initial admission, if the patient has a AND code status, we should put a blue bracelet on the pt.

True, but each shift should also be checking for correct arm bands as part of their daily (or nightly) routine. That way, if it falls off...or was never put on in the first place..., someone will catch it and fix it.