Hi! The last couple days at work have been extremely stressful. I work midnights for LTC and we've had an actively dying 80+ yr old who's code status changed a couple months ago from no code to full code. I've heard there was a recent law that passed changing a lot of resident's code statuses, and another nurse explained to me it was because the resident had a guardian, not a DPOA.
This resident has been deteriorating over the past couple of months, refusing meals and medications. He is probably a little over 80 lbs. The other night at work, he went into unresponsive status and began the actively dying process. His physician and family knew and were in agreement, do not preform CPR. His physician left his cell phone number behind in the event he passes, so we can get him pronounced immediately. This same physician who doesn't like on-call doctors treating his patients explained for us to not only have a nurse calling his cell number, but to have us page the on-call at the same time so SOMEONE would pronounce him immediately.
So, I arrive to work the other night with all of this going on and I'm stressing out. I go in his room to check his status and his family is at bedside. They leave the room so the CENA's can do their cares, and one of the family members lets me know that she will throw herself across his body if I attempt to preform CPR on him. I tell her that it wont get to that point, I have the Dr.'s cell number at hand and will be calling the on-call Dr. if need be to avoid all of this. I, out of courtesy, let all the other nurses in our facility know the situation so they can be prepared if I called a code. Luckily, I didn't have to the first night.
The next morning I explain the situation going on to the charge nurse (his status changed after she left work that day so she wasn't aware he was actively dying). I tell her about the CPR situation with the family, and my agreement I had with them knowing that technically I couldn't do that. She didn't come out and say I was in the wrong, but did say that if he goes that day when she's there they have to initiate CPR while others are trying to get him pronounced. I warn her about the family and their statements and hope it doesn't have to go to that point. That night I'm scheduled to work and find out he's still with us, but in worse conditions then he was the first night. Of course, it's time change night so my usual 8 hr shift is 9 hrs and I'm figuring he's probably going to go on my shift. Same family members are at bedside and this time they seem relieved I'm there because I said the night before I wouldn't perform CPR. So, I again make my courtesy calls to the other nurses in the facility.
Later in the night, one of the other nurses comes down to my floor and chit chats with me on the situation. She asks me what my charge nurse said about the CPR thing, and I explained she didn't necessarily tell me I had to do CPR, but told me she would do it if he passes while she's there. This nurse then asks me if it's against the law to not initiate CPR on a full code Resident. Immediately I think, uh oh... here we go. I tell her my plan is that if he passes, I have the CENA's calling the code while I'm calling the Dr. because I do not see the point in battling in the room with the family about doing CPR. She then states, "I don't know if I'd risk my license doing that." So, the rest of my night was spent in his room every 30 minutes checking vitals to see if he's beginning to go downhill more so then he already was. He didn't pass on my shift and I've been off the last couple of nights, so I don't know if he passed yet and how they handled the situation.
My question is, I know technically what we're suppose to do with full codes, etc. But, what would you really do if you were in my shoes? Would you really go through the dramatics and the trauma to the family to begin CPR on a resident that you know isn't going to come back from it, and you're only injuring the body more. Was I in the wrong by saying I wouldn't initiate CPR and would call the Dr. first? Ethical dilemmas are not fun!
I'm not certain this law exists? Where are you located? We would be able to get the family to agree to the No Code and the MDs at my facility would have no problem signing the order. The family should be looking into this, they need to be aware of the circumstances they are creating and position they are putting YOU in.
If he has no POA then he needs to get a guardian appointed. ASAP to make these decisions. Why can the doc just right the order for no cpr if there is no family to make the decision?
This man is totally appropriate for hospice. End Stage CHF is an appropriate dx for hospice...end stage dementia too (if that is the case)
If he has the order for CPR or Full Code then that is what you need to do legally. If you can call the doc fast enough and get an order to stop then you don't need to do cpr.
This and these type of situations need to be cleared up ASAP. It is hard when you are working nights and don't see everyone.
Specializes in Clinical Research, Outpt Women's Health.
The adult children as next of kin have the rigth to make the no code decision if the patient is out of it. I do not understand why that has not happened. The order to determine next of kin is very clear.
Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.
I'm confused also. The family wasn't able to get to the courthouse in several months?? Anyway, if he is a full code than you must run a code. Kinda sounds like the Dr. and DON should have had this problem taken care of already and have let the patient, family, and nurses down. Please let us know what happened. I'm not sure what you are supposed to do when you're coding a patient in LTC and a family member obstructs.
A doctor can make a hospice referral, and our health system's standing orders are that hospice is an automatic DNR if there's not already one in place. For God's sake, please don't let anybody torture that poor dying soul because they're worried about what's got to be about the dumbest law I've ever heard of.
So I have one sibling and no children, no nieces or nephews. If my family dies before me, and I have a sudden CVA, then you're telling me in your state I will be kept alive at all costs, regardless of any diagnosis or prognosis? Even if I did have family and there was no person with a POA for healthcare, I'm going to be a full code even though everybody knows I want to be a DNR?
Oh...my...God. Please tell me what state you live in, because if it's mine, I'm MOVING.
I attempted to look up this law to find out what it is with no luck. I'm going to have to get clarification from someone at my facility to find out what exactly was his situation, instead of hearing the different things from different nurses. But, from what I understand, there were several residents in our facility that changed from a DNR status to full code because of some technicality. It just so happens that this particular resident began actively dying.
He has a legal guardian, but she was not appointed as his DPOA. I didn't realize a MD could order the DNR, or he could order Hospice in this situation (kinda irritated that didn't happen).
I work tonight, so I'm going to find out more information with specifics because this is probably a situation I will be facing again in the future. UGH!!
Oh, and I live in Michigan. Thanks for your input so far!
If he has a legal guardian a court has already found him to be incapable of handling his affairs so he wouldn't be able to sign a DPOA. A DPOA gives someone the status to make decisions. This can be any person regardless of kinship status. If someone doesn't have a DPOA, the decision would automatically go to next of kin.
According to the Michigan bar association, if someone does not have a DPOA the hospital or family may have to go to the courts to establish guardianship. This has already been done. According to what I read online re: MI law, the guardian can do whatever he/she wishes in regards to the code status. http://www.michbar.org/elderlaw/adpamphlet.cfm
It really doesn't matter who is what to whom. If he's a full code, he's a full code and I am telling you, you had better initiate that code. Your license is in jeopardy if you do not. I am not guessing about this.
If you were in my shoes, would you consider paging the code blue and then picking up the phone to call the MD to have him pronounced as initiating the code? Or, would you attempt initiate CPR (fighting with the family in this situation), have your CENA's page the code, then have one of the responding nurses call the MD?
So, the Resident passed the evening of the last shift I worked, which was not surprising as he was mottling. I guess a nurse just happened to be in his room when he took his last breathe, got the same charge nurse that I spoke with that morning. She assessed that he had no pulse, told a nurse to get the charge cart and called the MD to have him pronounced. No paging Code Blue, no dramatics with CPR, no nothing. He left us peacefully :redbeathe
I'm still at a loss as far as getting answers to the legality question, but if I ever find an answer to this I will definitely post here!
Specializes in Geriatrics, Hospice, Palliative Care.
In this case, if the paperwork cannot be done to everyone's agreement (DNR), I might tell the family that I'm going to keep the patient's door closed to give them privacy, and that they are to call when they need assistance. Hopefully they will be bright enough to not need assistance until all hope has passed so that CPR does not need to be initiated. BUT - I would make it a priority to get the paperwork together.
NickiLaughs, ADN, BSN, RN
2,387 Posts
I'm not certain this law exists? Where are you located? We would be able to get the family to agree to the No Code and the MDs at my facility would have no problem signing the order. The family should be looking into this, they need to be aware of the circumstances they are creating and position they are putting YOU in.