Legal question regarding health care proxy and terminal wean?

[Oliver1234]

Hi all,

I had a situation at work recently where a patient was transferred to my facility (long term acute care hospital) from an acute care hospital to be terminally weened ..pt was ventilated and ended up having a stroke at the hospital and was no longer mentally there. before the stroke, the pt said she was ready to die to her family and was okay with it. They filled out a health care proxy in previous hospital. they were transferred to my facility thinking it was a hospice place and it was a mess. One of the higher ups and a doctor talked the family into staying and said we would create a hospice environment for them. so they stayed. I took care of this patient the next day when pt was to be terminally weaned off ventilator. Dr came in ( different one than before, and one who never helps anyone die peacefully but instead makes people live with no quality of life...sorry i could go on) anyways this doctor kept prolonging the wean and not allowing us to up the dose of morphine drip. Eventually the Dr said the health care proxy wasn't invoked and decided to completely ignore the families wishes and ordered meds, g tube feed, vitals and d/ced the morphine etc. the family was so upset and ended up calling the hospital they came from and had them acutely transferred. I am honestly sickened by this situation on so many levels. How can a Dr not invoke the health care proxy when the patient is clearly not capable of making their own decisions? the pt wasn't even conscious! the proxy was filled out before hand and we were given a copy. I don't understand how that is even legal and especially ethical! The entire family came to say good bye to the patient....I can't even imagine being that family. I personally said goodbye to both of my grandmothers with the help of Drs, nurses and morphine and if something like that happened I would have been beside myself. I am not sure what ended up happening to the patient at the other hospital but I am praying they are at peace now. Any incite or similar situations out there? Honestly, situations like this make me want to go into hospice nursing. Allowing people to Die with dignity is so important to me.

[MunoRN, RN]

That's actually a pretty serious case of malpractice and should be reported to both the board and the department of health.

The Physicians legal and ethical obligations is to follow the patient's known wishes, and when no evidence of the patient's wishes are available then decisions are deferred to the proxy, although they are also legally required to abide by the patient's known wishes. So there's really no question that stopping comfort interventions and instead switching to prolonging care was wrong, and could potentially be considered criminal abuse.

[KatieMI, BSN, MSN, RN]

Many of docs just cannot accept the concept of hospice and letting someone go in peace. This is the way many of them are trained and live, not counting the very obvious thing of "being reimbursed" for everything they do. It is not ethical and can border with abuse of privileges.

A patient, or, as in this case, proxy, has absolute right to refuse everything or anything in terms of treatment. In the LTACH I work, things like described happened mostly either from family disagreement, patients who belong to "hospital group" instead of single doc or from specialty services, like oncologist trying to talk fsmily into yet more chemo when patient is dying and proxy knows it and doesn't with more aggressive treatments. In this case, proxy is called and in the presence of one more licensed witness says "no". This means that the RN whose assignment include the patient can (and does) nothing above comfort measures or whatever coordinates with patient's code status. If there is continuing problem, the CNO is called to contact the doc's employer (in our case, the "host" facility) ethical committee.

I am sorry you had to go through this.

[Oliver1234]

I thought so too! I mean how can a Dr get away with that? Its unacceptable. Doing some research online before posting here, in my state (ma), a physician has to invoke the HCP when enterting into a facility. So at the previous hospital they clearly had no problem doing that, and at my facility they assigned the one dr that we all knew would ruin this. We have plenty to choose from and by right it should have been someone elses job by the way who covers who at my facility so it almost seems like a big scam thinking they could trick the family into keeping her alive and live a miserable next 3 years as a vegetable. Anyways so the dr used the only thing that he could by not invoking the proxy, and said somthing to the matter of how the pt needs to be evaluated by psych before able to use HcP... But pt was unconscious!!!!!!!! Come on!!!

[Oliver1234]

KatieMI

I am glad your facility has more people to call in like an ethics committee. I wish we had something like that. But at our place the Dr rules all. It's disgusting.. And situations similar to this has happened before (same dr). I think I need to find another job for multiple reasons!