Going against the pt's wishes...

[Cindy-san]

I took care of a pt for the first time the other day and the whole scenario really bothered me.

An 80y.o., very depressed since their spouse died (no one wants to address this, but that's another issue). Post-surgery came to us intubated (which is the norm) but my colleageues weren't able to extubate due to pneumonia. When I got the pt the other day, they had just finished traching, even though the pt had expressly stated to the mds, family and in their living will that they didn't want to be trached.

Despite being fully cognizant of this, the docs after a bit of pushing, convinced the family (who was also fully cognizant of the pt's wishes) that "it's just pneumonia" and the pt "will get over it, so let's trache."

After asking around, some of my colleageues were all for it (I get the impression that the nurse taking care of the pt when the decision was made was also pushing the family for it), but I don't think that was right. Sure pneumonia can be treatable, and respiratory is (for the moment) the only system "in failure," but I still don't agree with what went on. I understand when you lay out the options and the family chooses "everything" even though the pt doesn't want it (living wills aren't legally binding in my state), but actively pushing for something like this that's against the pt's wishes is wrong to me.

What happened to respecting the pt's wishes? Or advocating for them? Am I off base here?

[Batman24]

This has always distressed me. In the end many times the doctor lets the family make the decision even when the patient has made their wishes know verbally and in writing. I find it so sad that we don't respect our patients. Doctors are afraid of being sued so we read stories like this again and again.

[oramar]

I heard that there are states that are starting to pass laws which mandate the living will be honored. I wish I knew where and when.

[Pepperlady]

Any living wills I have seen usually differentiate between those conditions which offer some significant chance of recovery vs those that offer minimal chance of recovery.

For example, I see it as different if a patient comes in full arrest and has stated a wish not to be intubated vs pneumonia ....

And given an acknowledged depression how can he be considered compos mentis in decision making.

[Valerie Salva, BSN, RN]

Pneumonia used to be known as "the eldery person's friend" because it allowed people to die quickly, rather than linger for years with debilitating conditions such as s/p CVA, heart diease, cancers and so on.

[Pepperlady]

Still, there is a difference between hospital acquired pneumonia and community acquired pneumonia. Pneumonia in a post-op elderly patient wouldn't be considered abnormal and I would think it would need to be treated aggressively.

If the patient came in with pneumonia that would be, perhaps, a different story.

[StrwbryblndRN]

I hope my family respects my wishes.

The details do not matter, the fact remains that the pt did not want to be trached. Unless specifications were given the wishes should have been respected.

[Mr Ian]

And given an acknowledged depression how can he be considered compos mentis in decision making.

Because depression does not mean incapacitated.

The first impression is that the pt made their wishes known pre-op. So it seems easy huh?

Not so. It's a legal nightmare.

The thing is with 'decision making' that once the person loses the ability to make a decision - ie anaesthesia - how would you know if they'd changed their mind?

Anyone with decision making ability must also have the ability to change their mind.

If the doc did not trache - is he denying the pt the right to change their mind?

That's why decisions need to be re-considered and fresh opinions sought from those capable of giving fair and rational decision in the interests of the patient.

Death from hospital acquired infections can bring complex litigation too - Imagine if they let the pt die of pneumonia that the hospital gave them - are they culpable of manslaughter?

[truern]

This is why I want DNR/DNI tatooed across my chest so there's no misunderstanding my wishes.

[WalkieTalkie, RN]

This is why I want DNR/DNI tatooed across my chest so there's no misunderstanding my wishes.

Me too. I'm debating on when exactly I should have that done... I'm 26 now, but who knows, I could have a CVA tomorrow, you just never know!

[robred]

Here's my take on this: If the very depressed, but not incapacitated pt gave consent to surgery, but knowing the risks of surgery expressly noted on his Advance Directive that he did not want a tracheostomy...I wouldn't want to be neither the family member nor physician who signed the consent form. Given his expressed wishes under those circumstances which were not adhered to, I would think he would have a very strong malpractice lawsuit not to mention allegations of battery.

[shellsgogreen]

there was a similar case on my unit awhile back - the patient had expressed his wishes, and signed a dnr/dni - he was ultimately intubated, as per family, and he extubated himself three times before coding again, and by that time, he did not make it. the nurse who was taking care of him got into a screaming match with the md, as she felt he was not honoring an alert patient's wishes.

his response was, "well, he got his wish in the end anyway"