witnessing a DNR - page 2
We had a patient who was actively dying. The MD spoke with the family and they were deciding whether or not to make this patient a DNR. I went into the patient's room with the primary RN to see the... Read More
Dec 13, '12this seems like a HIPAA violation to me. I think your facility needs to talk to an attorney about what is really required in such an incident. Pulling people out of rooms in the middle of the night for ANY reason other than meeting their own loved one's needs is ridiculous.
Dec 13, '12Working in Risk Mgmt, I think you need to have your policy revisted. This is not ok in any US hospital in America. If it is, this is a crime! I would contact your administration or risk department for guidance. I think there is some ignorance on someone's part, just not sure who.
Quote from turnforthenurseRNWe had a patient who was actively dying. The MD spoke with the family and they were deciding whether or not to make this patient a DNR. I went into the patient's room with the primary RN to see the patient; their eyes were glazed over and they were agonal breathing. The patient's extremities were warm but after some time the primary RN & I noticed that they were starting to cool down and the patient started turning pale.
The decision was made to make this patient a DNR. Now we needed witnesses; we had some family members on the unit. I had a patient with a family member in the room, so i decided to ask them. The family member was already sort of awake and I politely explained to them that we have a patient just down the hall and there was a decision to make them a DNR but we needed two witnesses. The witnesses had to be unrelated to the patient/family members and they could not be employees of the hospital.
I told the family member they weren't obligated to be a witness if they didn't want to. The family member said to me, "Oh, but I was sleeping so good, and I don't think I can make it to the room...where is it?" "Just across the hall." "Oh ok, but I don't think I could make it...." and I reminded them they didn't have to be a witness if they didn't want to, and it sounded like they didn't want to do it. Then they started talking about all sorts of other random things before finally (reluctantly) agreeing to witness.
The primary RN was standing in the hall trying to usher me out and I was trying to speed things along...I really wanted to just tell this family member, "the patient is ACTIVELY DYING and if we don't get this DNR signed SOON, we may have a full code on our hands and that would be against the wishes of the family." I then realized that could be a HIPAA violation, so I kept my mouth shut.
We finally arrived to the outside of the patient's room and almost immediately the family member said, "Oh you don't need me" and started walking back, but I told them we needed TWO witnesses, unless of course now they are not agreeing to witness. They reluctantly stayed, signed the paper and then I escorted them back to their room.
It was not like I was trying to twist this family member's arm into witnessing this DNR, but it sure felt like it. In the past I have asked visitors to witness a DNR and they have all immediately agreed to it. I don't know, I was just annoyed by it and I wanted to get this off my chest, I guess! Sorry it was long. Thanks for reading.
Dec 13, '12Trust me, I am NOT okay with the policy. I agree, there are a lot of issues with it and I think it is wrong, but for whatever reason no one has ever said anything about it. Perhaps I can take the issue at hand myself to risk management or whoever.
The "witnesses" did not go into the patient's room.
Dec 13, '12Quote from turnforthenurseRNHow would they witness a person making themselves a DNR without going into the room? Even if the family makes a loved on DNR and the witness speaks to them in the hall, the witness still needs to at least sign a piece of paper with the pt's name on it. Anyway, go for making a change. Find the written policy and take it to some one. Don't be militant in you opposition to it. Go to risk management or legal and say "I have some concerns about this policy. One of my biggest concerns is that it violates HIPAA, and I am worried if someone filed a HIPPA violation against the hospital based on this policy."The "witnesses" did not go into the patient's room.
Dec 13, '12Agreed. I also wonder how having a "stranger" sign a document that I am assuming is stamped/stickered or some how labeled with the pt's name, dob, age--or even involving them in witnessing--is not in violation of HIPPA law?
Very much worth further discussion/evaluation.
At every facility I have ever worked, it has always been a family+MD conversation= MD order.
Maybe you could provoke this very much needed second look at your facilities policy somehow?
Inquire with the QI folks or even ethics committee?
Just thinking off the top of my head...
Dec 13, '12I know it's been said but this policy is weird. I wouldn't feel comfortable as a nurse or visitor/witness in this situation. At my hospital it is a written document signed by the attending physician, until it is signed by the ATTENDING it is not valid, no random strangers needed. I would ask around, see if this is indeed policy, maybe it can be changed since it could come back to hurt the hospital.
Dec 13, '12I wouldn't do this again. This sounds bizarre. Most doctors I have worked with talked to the family at length and then wrote the DNR with progress notes detailing the conversation with the family. Some docs would prefer to have a nurse in the room as a witness to the discussion with the patient or family, but that's it. I have witnessed countless DNR discussions and orders and never remember a problem and have never even heard of anything like this. I have seen more problems with running a code when the patient was supposed to be a DNR. Now, Power of Attorney, that's a different story.
Dec 13, '12Huge HIPAA violation if this were to occur. No requirement from any regulatory agency to do this, either.
How does the visitor feel who doesn't want to get involved? Does he feel that maybe his family member will not get the best care if he doesn't cooperate with the staff on this one? Spell this C-O-E-R-C-I-O-N.
I can't believe this whole situation. Is this a homework thing for somebody in a non-healthcare major? I never heard of anything remotely resembling this "policy" in all my mumblemumble years of nursing. Ann Landers used to blame this sort of thing on Yalies.
Dec 13, '12I agree with everyone else... this is nuts. I've never seen a DNR require two strangers to witness. When I worked in the hospital, we had many patients who were made DNR or who came in DNR and needed their orders renewed. The Attending Physician wrote the order and it was verified by the nurse- as in signed off like you would any other order. The only thing with a DNR was that it needed to be written by the Attending. And it is most definitely a huge HIPAA violation to disclose to a visitor that Mr. Jones in room 1A is now a DNR.
Dec 13, '12The other thing--be 100% sure of this policy. Don't take the word of a coworker. Heck, don't even take the word of the NM. See it in writing. If you are the middle of a HIPAA violation while you a trying to comply with a policy that does not exist, this can mean big trouble.
Dec 13, '12I've never heard of such. I think I would much rather code a patient then follow such a policy. It makes no sense having a random person sign a document about code status of someone they do not know.
Dec 13, '12something is fishy about this story...Don't know if its the policy, or the details, or the "story" in general...Last edit by smurfynursey on Dec 13, '12