Long-term Care Advance Directive

[djewel]

Hi,

I was wondering if a pt. has an Advance Directive, and it does not conscent to CPR, then is'nt that all a nurse needs to have in the chart to not start CPR? I am being told by my DON that CPR should have been done on a pt. She did not have a DNR order, just the AD. I am told I should of sent her to the hospital or started CPR. The DPOA was out of town, and I could'nt locate him until after the death. He asked nothing about whether I did CPR, but the Medical Records is saying I should of done CPR since there was no DNR in the chart. I am so confused. This lady was a readmit the day before she died, and the hospital information also said she was a DNR, although we did not have that order. ALso, I called her sister and she told me not to do CPR. I am afraid to call the DPOA and ask him. What are the state regs on this, does anyone know for Kansas? Is my DON right, or is she denying the AD. This lady had COPD, and the family knew she was not expected to live very long. Can anyone help me on this, please. Thank-you!

[RoxanRN]

An Advanced Directive is NOT a DNR. It only tells healthcare providers what their wishes are. The doctor must still write the DNR order (I can't state the regs). DNR orders must also be rewritten with each admission to any healthcare facility (as an ICU nurse, I cannot accept a DNR order from any outside facility, even another hospital). However, if there has been a DNR in place a previous facilities, the doctors will (generally) verify wishes with the family/patient (do they still want DNR?) and write for DNR.

If I am understanding your post... you had a patient with an AD but not a valid DNR. In this case, you must code the patient.

On an aside..... if you ever transfer a patient with a valid DNR by ambulance to another facility (NH to hospital, hospital to NH, hosptial to hospital, etc), always, always, ALWAYS include a copy of the valid DNR with the paperwork (the medic might request to see the original order for verification). Without a valid DNR in hand, they must code even the most terminal until medical control tells them they can terminate the it. If there is any question to the validity of the DNR, have the doctor write it again on the transfer orders.

[djewel]

Okay, this re-admit was done 24 hr. ago before my shift, and this nurse tells me that this lady was modeling upon return from the hospital. I could'nt find anything in the chart except the AD, and thats what I went by, with the other nurse telling me she was a DNR by transfer sheet of the hospital. The family, then tells me she has a living will, and do not resusitate. Was I still surpose to do CPR, knowing her family is telling me not to, and she has a living will not in the chart? Thanks for you help.

[djewel]

Also, how long does the Nursing home have to update the chart after a readmit? Nothing was redone in the chart, after this readmit 24 hrs after. Then I am the nurse comming on duty, working part-time not able to find anything in the chart only the AD and the DPOA, in which the DPOA was out of town and not available. Should'nt the NH have had everything in place. I had an hour and 15 min to work before this pt. passes away, trying to take care of 40 other pt.s also. Thanks so much!

[RoxanRN]

Please take the following with a grain of salt. This is arm-chair quarterbacking at its best (and I hate it ). And I have never worked NH/LTAC (those who have (or even a legal nurse) would be better suited to answer the questions).

Given her presentation upon re-admission, I probably would have been on the phone to the doctor to update the orders (at least the DNR if nothing else).

[djewel]

Can't a living will or Advance Directive be the same as the DNR? I don't really understand why you have to have a DNR, if you have an AD or LW. I had been gone for several days, and the day nurse did not report that this pt. was actively dying. I called the nurse on the eve. before and she told me to go by the hospital transfer sheet that said, DNR. But the DON says we can't use that? This eve. nurse said the pt. was actively dying on her shift, but was a re-admit, so the hospital dismisses her actively dying. It just does'nt make since to me. Here I am an hour or so into my shift, finding her dying, and have minutes to an hour and 15 min, to call the DPOA which was unavailable, then the AD says to not use CPR, along with the sister that I got ahold of on the phone, she says, she has a living will, do not resusitate her, so with all of this info. I did not do CPR. So is this a law that you have to have the DNR in the chart, is it my responsiblity to get it, I was just thinking with everything aboard, I was doing the right thing. I though MD records was surpose to have everything ready for the nurse, to quicky assess whether to resusitate or not to resusitate, there were no clues from the MD records not even an updated face sheet for information, and then I am called into the Don's office to make out a statement, and later reviewed it was a disciplinary form, which is being appealed by myself right now. The other nurse calls the state and they tell her all we need is the AD? I am so confused. Thanks if you can help.

[RoxanRN]

Like I said, I've never worked in LTAC, only hospital. I know if a patient is a DNR at a NH and is admitted to me, I have to have an order written on the chart for DNR. I can't take the NHs DNR.

An Advanced Directive is just that... a directive the patient makes in advance of incompatication with the goal of directing the family about their ultimate wishes when they are not able to speak for themselves. And unfortuately, the family is not bound to follow the AD.

And as for the MD having everything in order for the nurse.... it rarely, if ever, happens.

As for legal issues, you might want to consult an attorney if you have questions about an ADs validity.

[djewel]

Thank-you for your all of your imput.