91yr old, end stage everything, family wants "everything" done despite multiple talks with MD's regarding what exactly is their expectation and how its not going to happen quite that way.. So when the pt coded, we got the family all close and personal with the code and all the rib breaking so that they could see that indeed we are doing "everything" .
Now they want to sue the hospital for battery and ABUSE because we broke the pts ribs during cpr....
I do believe it comes down to money, harsh as it may sound, but if someone who has no chance of recovery decides they want to be a full code just a little longer so they can dance at someone's wedding (or whatever), would they still insist if they were the ones to pay?
I don't think we should take away a mentally competent person's right to make healthcare decisions. If you take his rights to self determination you are taking away my rights too.
If a person is unable to make decisions and has elected in writing to have no CPR, dialysis, feeding tube or mechanical ventilation etc. , then the next of kin should not be able to override their wishes either.
edited to add: IF studies showed that doing CPR on an elderly person with severe osteoporosis and advanced age has no benefit, then this should be added to the algorithms for BLS and ACLS.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
I am tired of adult children who want to keep a parent alive forever so that they can have a free place to live and take the parent's social security and retirement funds.
The legal obligation of the POA is to communicate what they believe the patient's wishes to be, and to ensure that any wishes the patient has already clearly expressed are being honored, they don't actually have the legal right to oppose or negate the patient's expressed wishes. The only time they can legally rescind a DNR is when they do so because there is reason to believe the patient's wishes changed after communicating a desire to be DNR, or if there is reason to believe their DNR preference didn't apply to the particular situation.
Unfortunately it's far easier to not fight a family/POA when they try to go against the patient's expressed wishes so there are situations where the wrong thing happens, which I've seen at other facilities I've worked at. One thing I like about my current facility is that they don't take part in violating the patient's expressed wishes, if a family wants everything done at the end, despite the patient having expressed other wishes, and the family says to do everything because that's what they want, we explain that we can't do that. And in a situation where CPR would be of no medical benefit, we don't offer that even if the patient wants it which negates the need to sort out what the patient wants vs what the family wants in the first place.
And in a situation where CPR would be of no medical benefit, we don't offer that even if the patient wants it which negates the need to sort out what the patient wants vs what the family wants in the first place.
What? You make the patient a DNR even if the patient wants to be a full code? At what point is this decision made with regard to the patient's mental status?
What? You make the patient a DNR even if the patient wants to be a full code? At what point is this decision made with regard to the patient's mental status?
We make them a DNR due to medical futility.
Resuscitation is a medical intervention, and just like all other medical interventions the patient cannot simply chose an intervention that the Physician doesn't agree would be of any benefit. For instance, a person with no indications for open heart surgery couldn't go to a surgeon and say they want the surgery and the surgeon must provide it for them, it's up to the surgeon to determine if that's an intervention that's appropriate to offer the patient.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
The legal obligation of the POA is to communicate what they believe the patient's wishes to be, and to ensure that any wishes the patient has already clearly expressed are being honored, they don't actually have the legal right to oppose or negate the patient's expressed wishes. The only time they can legally rescind a DNR is when they do so because there is reason to believe the patient's wishes changed after communicating a desire to be DNR, or if there is reason to believe their DNR preference didn't apply to the particular situation.
Unfortunately it's far easier to not fight a family/POA when they try to go against the patient's expressed wishes so there are situations where the wrong thing happens, which I've seen at other facilities I've worked at. One thing I like about my current facility is that they don't take part in violating the patient's expressed wishes, if a family wants everything done at the end, despite the patient having expressed other wishes, and the family says to do everything because that's what they want, we explain that we can't do that. And in a situation where CPR would be of no medical benefit, we don't offer that even if the patient wants it which negates the need to sort out what the patient wants vs what the family wants in the first place.
And that's the thing I miss about the "good old days." If CPR would be of no medical benefit, we didn't do it. We had "slow codes" or "show codes", but I don't remember torturing patients by keeping them alive when they had no hope of a meaningful survival. A physician always has the option of "calling" a code if he or she believes it to be of real benefit, and they used to exercise that option. Now, in the days of 24/7 visiting and families hanging out at the bedside during emergency procedures, we code folks who shouldn't be coded just for fear that the family will pitch a fit or sue if we don't. That's truly sad.
You didn't answer my question. At what point re: the patient's mental status is the decision made?
Take the example I used earlier in this thread about the stage 4 with mets everywhere, terminal, but alert and oriented. He was going to die from the cancer...he knew it, we knew it. No one knew if he would recover from a code, and many were skeptical that he would.
Would his case be one in which the docs would make him a DNR against his wishes?
Or are you talking about the unresponsive but stable patient who can't move, can't eat, can't swallow and keeps coming in for aspiration pneumonia because she can't handle her own secretions?
I'm just trying to get my mind around your hospital's policy.
Resuscitation is a medical intervention, and just like all other medical interventions the patient cannot simply chose an intervention that the Physician doesn't agree would be of any benefit. For instance, a person with no indications for open heart surgery couldn't go to a surgeon and say they want the surgery and the surgeon must provide it for them, it's up to the surgeon to determine if that's an intervention that's appropriate to offer the patient.
This sounds highly unethical. Why should a doctor have the right to determine whether a person should have resuscitation attempts that may permit them to live longer if they so wish? This is a decision for the patient to make, for it is their life, or for their trusted decision maker to make, in accordance with the patient's wishes. A competent patient has the right to make decisions about their care. In the event of incompetency, power of attorneys etc. take effect. There is a big difference between a person with no indications for open heart surgery requesting the surgery and a person requesting to be resuscitated. Quality of life can only be determined by the person living the life, i.e. the patient, and if resuscitation results in a patient prolonging their life and they wish to prolong their life, they have the right to make that decision. The physician's duty is to explain to the patient their medical condition, explain treatment options and the risks and benefits of those options, and then let the patient, or their designated decision maker or next-of-kin, who have the right to be fully informed about treatment options, make the decision in regard to treatment.
I will be watching the care my older family members receive very carefully. I will not hesitate to contact my state medical board and/or a lawyer if necessary.
This is an interesting site. Ethics-wise--at least according to this bioethicist--it is acceptable to DNR patients where CPR would be medically futile. However, if you read the cases, the ethicist doesn't have the balls to come right out and say, "Yes, DNR this patient." If an ethicist can't advocate for it in a hypothetical situation, I wonder how many doctors would do it in real life.
Muno, how many cases are you personally aware of that a doctor has told the patient or family that the patient has been DNR'd due to medical futility, although the patient or family doesn't want it?
Here is another one that states doctors can DNR a patient, but, again, it encourages conversation with the patient or family.
Medically futile is medically futile, regardless of talking with the patient or the family, but not a single one of the web pages I have read advise doing so without talking to them. Which leads me to believe that if the patient/family isn't persuaded, the DNR won't happen.
This sounds highly unethical. Why should a doctor have the right to determine whether a person should have resuscitation attempts that may permit them to live longer if they so wish? This is a decision for the patient to make, for it is their life, or for their trusted decision maker to make, in accordance with the patient's wishes. A competent patient has the right to make decisions about their care. In the event of incompetency, power of attorneys etc. take effect. There is a big difference between a person with no indications for open heart surgery requesting the surgery and a person requesting to be resuscitated. Quality of life can only be determined by the person living the life, i.e. the patient, and if resuscitation results in a patient prolonging their life and they wish to prolong their life, they have the right to make that decision. The physician's duty is to explain to the patient their medical condition, explain treatment options and the risks and benefits of those options, and then let the patient, or their designated decision maker or next-of-kin, who have the right to be fully informed about treatment options, make the decision in regard to treatment.
I will be watching the care my older family members receive very carefully. I will not hesitate to contact my state medical board and/or a lawyer if necessary.
Performing an intervention that has no indication for it's use in that patient is unethical.
The reason why we don't just let people chose to have open heart who don't need it is that we don't do things to people that serve no purpose, by definition medically futile CPR serves no purpose.
Here is another one that states doctors can DNR a patient, but, again, it encourages conversation with the patient or family.
Medically futile is medically futile, regardless of talking with the patient or the family, but not a single one of the web pages I have read advise doing so without talking to them. Which leads me to believe that if the patient/family isn't persuaded, the DNR won't happen.
Of course you should attempt to get the patient/family on the same page instead of declaring medical futility. If they agree to the DNR order then that isn't declaring medical futility. Some places don't typically declare medical futility, some do.
icuRNmaggie, BSN, RN
1,970 Posts
I don't think we should take away a mentally competent person's right to make healthcare decisions. If you take his rights to self determination you are taking away my rights too.
If a person is unable to make decisions and has elected in writing to have no CPR, dialysis, feeding tube or mechanical ventilation etc. , then the next of kin should not be able to override their wishes either.
edited to add: IF studies showed that doing CPR on an elderly person with severe osteoporosis and advanced age has no benefit, then this should be added to the algorithms for BLS and ACLS.