Do Not Resuscitate Order for suicidal patient

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I have a question. I have a case study that I am struggling with. I have a patient who attempted to commit suicide by a self inflicted gunshot wound. His wife died a week prior and he left a suicide note stating he was too heartbroken to go on. He is non responsive, right pupil fixed and dilated. Very large extended family show up. A neurosurgeon was consulted and he says prognosis is not good even with surgery, however, family still wishes for the surgery to be done anyways. Once the patient is prepped and in the OR they receive a call that the patient signed a DNR order 2 days ago. AS the OR nurse what are your legal and ethical issues now? Do you honor the DNR or the family's wishes?

I have to explain what my legal and ethical issues are which originally I was leaning towards if there is a DNR order present then you honor that despite the circumstances because the man had to be found in his right state of mind when he signed, right? And if the patient needs surgery does that exemplify the DNR order? I have researches where some say yes and others say no.

Specializes in PICU.

The DNR would not apply to a surgical procedure. The only issue that could arise is if the patient coded in the OR. Most of the tyime DNR does not apply for a surgery. So there would not be an issue with the surgical procedure itself. DNR is only related to if the heart stops to not resuscitate, but this case is a surgical procedure. The ethical issue would be if the surgery itself is just.

Specializes in Critical Care.

"the patient signed a DNR order two days ago" would typically refer to a POLST form, since advanced directives don't establish DNR status, they express wishes that a Physician may interpret to then enter a DNR order. Since enacting and DNR through a POLST is done by a Physician or other LIP, part of the expectation is that they evaluate whether the patient is able to make that decision. It would be a stretch to assume the Physician inappropriately entered an ongoing DNR order without any evidence at all that it was inappropriate.

Family can't actually override the patient's stated wishes unless their is a valid reason to nullify those stated wishes, the requirement of surrogate decision makers is to ensure the patient's wishes are followed, even if the surrogate decision make doesn't agree with those wishes.

Specializes in Surgical, Home Infusions, HVU, PCU, Neuro.

Aspen University?

The purpose of the case study is to get you to research and find information that backs what you are choosing. These are some ethical situations that you could very well face in practice, if the DNR is upheld what legal ramifications could be faced? You have information that the DNR is coming into play while you are in the OR, does the family stating they want everything done supersede your moral and ethical involvement and why or why not. There has been a lot of stories on patient assisted suicide, would this fall in that category? You are not getting graded on a "right" or "wrong" answer, use reputable sources cited and reference in APA, Google scholar is great- try searching suicide attempt with DNR, I think that's what I used. There are articles available

Just to throw it out there- my facility does let a patient decide to up hold their DNR in surgery if they fill out a form and discuss it with both surgeon and MDA. All parties sign to the agreement. I've only seen it twice- both in cancer patients.

Like others said, otherwise the DNR is suspended in surgery. Interesting twist about the guy being suicidal. If he was in a coma though, did the family put it in place anyway?

As an OR nurse, I have done many cases I don't agree with at the decision of family. Usually giving Grandma a peg tube because she isn't eating. Poor frail 80 lbs, can't move, bed sores, no life but pain, and the family just can't let go. Makes me sick. But unfortunately it's not up to the OR nurse.

The best I can do in questionable consent isseues is call risk management/ethics line for guidance. Then I do my job giving Grandma the best care I can.

1 Votes

Have you considered that patient usually have to be a "full code" for surgery and usually for ~ 24 h after - after which time the physician should discuss with the surrogate decision-maker what the plan is going forward. So - for you in the OR it is irrelevant if the patient's code status has to be reversed for surgery. Regardless of the document signed 2 days before.

As somebody else pointed out DNR means do not resuscitate - patients are still being treated unless they receive comfort measures only.

DNR itself is a medical order and if on a POLST you have a portable medical order.

But in that case it seems straight foward. He shot himself into the head. The surrogate decision maker asked for surgery. After surgery the physician discusses further code status.

The surrogate decision-maker should also discuss with the physician what the longterm results could be - disability etc.. to make an educated decision about how far to go in his care.

In order for the DNR to be honored, the patient would have to be mentally stable/competent and be presented with information he can understand to make an informed decision about what he wants. Kind of similar to how a patient can’t be sedated prior to signing informed consent for a surgery. The questions I have about this case are:

Does the hospital perform a mental assessment on patients before allowing them to make changes to their advanced directives?

Does the hospital have policies/procedures for suicidal patients and whether that person's DNR is honored or dishonored?

Is there documentation showing the current advanced directives compared to the previous advanced directives? Were there any drastic changes in these advanced directives after his wife died? If so, what were the changes?

Is there a history of suicidal ideation or mental health treatment, and is it documented in the medical record? (documentation that notes his mental status before his wife died, compared to after)

Can the family attest to his behavior before his wife died compared to after; did they notice any drastic changes in his behavior? Was he trying to give away his personal belongings? Was he unusually happy/hopeful?

Is there a living will? A next of Kin?

1 Votes
Specializes in Psych, Addictions, SOL (Student of Life).
On 9/12/2018 at 4:02 PM, GrumpyRN said:

DNR does not mean Do Not Treat.

This - When my mother who was suffering from dementia had a hemoglobin of 4. We as a family requested diagnostic procedures to find out if she had a bleed. Namely a colonoscopy. Everyone we talked to said "She's DNR" I said just because she has a DNR doesn't mean we don't diagnose and treat problems that arise.

Hppy

5 Votes
On 9/19/2018 at 6:25 AM, nutella said:

Have you considered that patient usually have to be a "full code" for surgery and usually for ~ 24 h after - after which time the physician should discuss with the surrogate decision-maker what the plan is going forward. So - for you in the OR it is irrelevant if the patient's code status has to be reversed for surgery. Regardless of the document signed 2 days before.

As somebody else pointed out DNR means do not resuscitate - patients are still being treated unless they receive comfort measures only.

DNR itself is a medical order and if on a POLST you have a portable medical order.

But in that case it seems straight foward. He shot himself into the head. The surrogate decision maker asked for surgery. After surgery the physician discusses further code status.

The surrogate decision-maker should also discuss with the physician what the longterm results could be - disability etc.. to make an educated decision about how far to go in his care.

Why do they keep the patient FC for 24 h?

On 2/1/2019 at 8:04 PM, indienurse said:

Why do they keep the patient FC for 24 h?

Because of post-op status and potential for complications after the surgery. Risks from anesthesia, surgical procedure, etc.

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