Is there a gray area to a DNR order?

[Joybelle517]

We had a resident at the nursing home in Wisconsin I work at die at the breakfast table about a month ago. She was being fed oatmeal when she suddenly dropped her head, wasn't breathing, non-responsive, and was bluish.

The RN on duty called me and another nurse to the resident's room where we immediately started assessing the situation. She was a DNR, but we had to make sure she wasn't choking.

I got a pulse on her, but she wasn't responding and not breathing. The RN put a glove on and did finger sweeps while the other nurse went to get a suction machine. I was trying to get some kind of response from the resident. She didn't respond to any stimuli. Nothing was brought out of her mouth but some phlegm and bits of oatmeal.

While the suction machine was being set up, I lost her pulse. She was sitting in her WC during this entire time. We suctioned her, but didn't bring up anything more than what the finger sweep got.

We got her into her bed, where we took a BP and apical pulse. Nothing. So it was a done deal.

We called the family and the coroner ruled her death the result of CHF. Just another day at the nursing home, right?

Well, it just so happens that the housekeeper who was present that day in the DR reported to the granddaughter, who is her best friend, that 'Grandma' didn't die from CHF, but that she was choking, and we stood around watching and did nothing to help her because of her code status.

The state was called in to investigate and they put our facility into an 'immediate jeopardy' status. Their beef was that we didn't attempt the Heimlech manuever in an effort to clear her airway, if it was in fact blocked.

When I was interviewed by the state rep, she asked me why I didn't perform the Heimlech. I told her that I felt it was better to perform manuevers that would get her breathing again, if she was choking, and since the CNA stated that she'd had nothing but oatmeal, it was fruitless to do the Heimlech.

We have been fined big time, but without an autopsy, they cannot prove she died from choking, however, this is now the dilemma....

If a resident has a DNR order, when do we draw the line? For instance, if she had been choking and her heart stopped as a result, do we initiate CPR because she didn't die from natural causes? What if she'd been eating in her room, and when the tray is picked up, she's discovered not breathing and no heartbeat. Even if she had been choking, do we initiate CPR? And what about the liability of doing so? Where do we shade in a gray area when it comes to a DNR status?

According to the DNR sheet attached to the DNR papers in the resident's chart, it specifically states that while we will perform duties to prevent death according to their wishes, we WILL NOT perform chest compressions once the heart has stopped. There are no exceptions listed, such as "unless you have died from other than natural causes, i.e. choking".

I understand a DNR order to mean "once I have died, do not bring me back regardless how my death occured".

The DON is getting policies on the 'what if's' this week, but have any of you ever been in this situation or have any idea what the laws on these scenarios really are?

I was doing a search on the web to find this kind of info out, but couldn't find anything useful but this forum.

Thanks.

[meownsmile, BSN, RN]

Just what makes the housekeeper qualified to decide if someone was choking or not? If she noticed something that indicated to her that the resident was choking why didnt she jump in and do somthing? Just makes ya wonder if the residents daughter asked her "friend" those questions. I hope the housekeeper is out looking for another job.

Was the patient feeding herself? Being fed? There are a lot of things that might be a deciding factor in whether there actually was a choking incident or not and whether a person feeding her was being attentive enough to her to recognize she was choking.

I wonder if there were omissions in the charting, because they had to base the investigation on something other than a housekeepers second hand knowledge. I would think her opinion and any testimony in a court would amount to hersay and not be admissable anyway, since it sounds like she only heard/saw part of the situation. I dont think the state has the authroity to override a DR in deciding cause of death. You stated she was in the dining room and you(or her nurse) took her back to her room where you suctioned her. What did the housekeeper follow you?

I still think there must of been some big holes in the charting.

Sometimes people die and there just isnt anything anyone can do.

[Noryn]

Wow what a grey area. At one of our local nursing homes a patient was a DNR however was in decent shape--feeding himself when he became choked on a hotdog. The staff there did the heimlich however the patient stopped breathing so they did CPR. The family was livid at this. God bless some of these families.

Anyway documentation of these events is what will make or break you. If the patient was just eating then like you said dropped their head and died then you need to document everything. The problem is that most people just dont die in my experience. If they are having a massive MI or if they throw a clot they gasp at least a few times. This could be confusing because were they gasping because of choking or because of another process. I would have documented if the patient had been coughing prior to dropping their head, if they had struggled to breathe, etc.

This situation is tough--I would have been really tempted to code the patient and call 911. Most advance directives will contain something like suffers from a terminal condition so your defense if you felt as if it was the case would be that choking is not necessarily terminal if treated.

Advance directives or DNRs arent always set in stone. In surgery for instance from what I hear but also in trauma cases.

That housekeeper wont be able to override your judgement on whether the patient is choking in a court of law or in an investigation I wouldnt think. Also I dont know how the state could overrule the coroner.

The heimlich may have been an appropriate intervention. There could have been a large clump of hardened oatmeal or even a foreign object.

[Joybelle517]

Just what makes the housekeeper qualified to decide if someone was choking or not? If she noticed something that indicated to her that the resident was choking why didnt she jump in and do somthing? Just makes ya wonder if the residents daughter asked her "friend" those questions. I hope the housekeeper is out looking for another job.

Was the patient feeding herself? Being fed? There are a lot of things that might be a deciding factor in whether there actually was a choking incident or not and whether a person feeding her was being attentive enough to her to recognize she was choking.

I wonder if there were omissions in the charting, because they had to base the investigation on something other than a housekeepers second hand knowledge. I would think her opinion and any testimony in a court would amount to hersay and not be admissable anyway, since it sounds like she only heard/saw part of the situation. I dont think the state has the authroity to override a DR in deciding cause of death. You stated she was in the dining room and you(or her nurse) took her back to her room where you suctioned her. What did the housekeeper follow you?

I still think there must of been some big holes in the charting.

Sometimes people die and there just isnt anything anyone can do.

The housekeeper was fired for violating HIPPA law, and the CNA feeding the resident was fired because she continued to attempt to feed her after she'd stopped breathing.

The state didn't go on what the housekeeper said, they just started the investigation into the incident based on what she'd told the family. We were specifically asked if we'd performed the Heimlech. None of us had, and that alone is what got us. We didn't make sure she had a patent airway and we should have, by taking a couple breaths into her mouth.

However, that's really not the issue I'm looking at. I'm looking at the fact that she was non-responsive when I arrived and lost her pulse about 60 seconds later. She was a DNR but I'm being told that I should have called a code and started CPR since she could have died from other than natural causes.

I just want to reiterate that I don't believe she choked to death. There is no evidence of that, and as a professional who was present, I believe she died from CHF. My grandmother was in a hospital and she died the same way.

She was getting set up for breakfast and being discharged when she fell back on the bed after stating she couldn't breathe. And that was that. She went unconscious and there was nothing they could do, in spite of being a patient in a CCU unit in a big hospital. She was just 63.

You are right. Sometimes people die and there isn't anything you can do, but I want to know, do I violate a DNR order once someone has died, regardless of the circumstances?

[Joybelle517]

Anyway documentation of these events is what will make or break you. If the patient was just eating then like you said dropped their head and died then you need to document everything. The problem is that most people just dont die in my experience. If they are having a massive MI or if they throw a clot they gasp at least a few times. This could be confusing because were they gasping because of choking or because of another process. I would have documented if the patient had been coughing prior to dropping their head, if they had struggled to breathe, etc.

I wasn't present in the DR, but the resident was at a feeding table where there are several other residents with CNA's feeding them. All of the CNA's agreed that she didn't cough at all...that she was eating one moment, and was dead the next. Just like that.

[CoffeeRTC, BSN, RN]

IF she showed signs of chocking...coughing, drooling I would have done the heimlich manuver. It sounds as if she just died and the fact that she was in the DR eating was secondary.

[Noryn]

This is really really tough. Most administrations are not that supportive either. I honestly think though unless they are dying of natural causes or what is stated on their advance directives then you do everything.

There are always going to be exceptions to the rule. Probably a lawyer would be a better resource as they would know the laws in your state. I say exceptions though because lets say you have a patient who is a DNR and they get an overdose of morphine or ativan--you would still code them. There are many terminal cancer patients out there with a DNR card however if they are in a car accident then they are a full code.

Again though it goes back to the diagnosis or disease process. Once most disease processes get to that point heroic measures will do little except to prolong suffering however things such as choking or trauma do not have the same end results as they can be corrected (unlike COPD or cancer).

The CNA kept feeding her after she stopped breathing? Yikes.

This really is a hard situation. The patient probably should have been coded. You stated that you thought she died from CHF but that would be really sudden. I just havent ever seen someone able to swallow food then all of a sudden die from something chronic like CHF. Usually their respirations become labored or shallow and it takes at least a few minutes.

Again though this is hard--those investigators I guarantee spent hours going over the situation and even I have probably spent 15-20 minutes thinking about this at least. You had 1 minute--there is a big difference.

[delmar]

Having previously worked Risk Management, I can tell you,

this case is a tough one. First of all, you facility should

contest the findings of the state surveyor AND the fine.

Hard to guess, but would this frail, elderly lady w/ mult med

probs have survived the Heimlich?