Reamed for ordering an ethics consult

[WalkieTalkie, RN]

This story is being posted with no identifying information to protect the innocent parties involved.

I am an ICU nurse. Last night, I was taking care of a patient in her late 70s who has been in the hospital for about a month now. She is septic and had a colectomy performed in early January due to c. diff colitis. Her abdomen remains partially open. She was only recently extubated and is not doing well. She has developed a secondary pneumonia, has terrible edema and wounds, is in great pain, can barely move, and is certainly suffering by all standards. The patient is confused at times, but also mouths and sometimes (when able) verbalizes that she does not wish to have this type of treatment.

The family approached me last night and told me that they have decided that they would like to make her a DNR/DNI. They told me that she never wanted this kind of treatment, and that since she is not getting better and the possibility of her recovering is slim, that they wish not to "code" her if her heart would stop beating and that they do not wish for her to be on the ventilator again.

As I would normally do in this type of situation, I paged the surgery team in charge and told them about the family's request. They were annoyed that I had even paged them. Even though they were in house, they did not come up to the room (this was around 2100). The chief resident spoke with one of the daughters but then refused to write a DNR/DNI order and did not talk to me again. The daughter was upset and nearly in tears and told me that she felt bad for asking. Apparently, the chief resident told her that there was "a chance" the patient could get better in "three months" and that she didn't need to be a DNR. I explained to the daughter, husband, and patient that there is nothing wrong with discussing this, and that if that is their wish, then they do have the right to enact it. I also explained that DNR/DNI does not mean we wouldn't treat her any differently, and we would still give her all the meds, abx, wound cares, etc, if that is what they would like for us to do. I told her that since the surgery team was not on the same page with them, that I would page the ethics consult person, which I did.

After initially speaking with the ethics consult, I was instructed to page the patient's attending. The chief resident had failed to even mention the DNR request to him. However, he basically reiterated to the family that the patient "might get better in three months" and that she "might" make it, doesn't need to be a DNR...yada yada. Meanwhile, the entire family is extremely upset as it has taken them a lot of time to make this tough decision, and they feel like they are not being listened to. I tried to speak with the attending after he got off the phone with the daughter, but he hung up the phone.

I then paged the ethics consult again to let her know what had happened. She agreed with me that not everyone was on the same page, and that there was definitely an ethical dilemma, and that she would come in to speak with the family in the morning. I charted that I had done all this (and with whom I had spoken to), mainly to cover my bases in case the patient would have coded during the night. The family thanked me for sticking up for them and even told one of the other nurses how appreciative they were for what I had done to help them in the situation.

Apparently, the chief resident must have read my electronic documentation this morning, because she called me and was infuriated that I had called ethics. She told me that it was "inappropriate" and that apparently "you don't understand what's going on with this patient." She asked me why I had called ethics and I told her that as a patient advocate, when a patient/family approaches me with the request to make their loved one a DNR/DNI, it is my duty to accept their wishes and that when not everyone is on the same page, a mediator is needed so that we can do what is best for the patient. She got even more upset and asked to speak with my charge nurse, who relayed the exact same information to her.

I can't believe I got chewed out for this! I printed out the policy and procedure regarding an ethics consult, and I followed it completely. I've previously had a decent relationship with this resident, and now I'm afraid what's going to happen when I go back to work and need to call her for something. :angryfire

Has anyone ever had this happen to them?

[Magsulfate, BSN, RN]

I've never had this happen to me. It sounds like you did the right thing. Maybe the surgeon will realize this once the ethics person talks to him/her. It doesn't matter if the surgeon gets mad at you, you did your job and you did it well. That is what you're there for. You CANNOT deny the family and patient's wishes just because the doctors want to keep this patient alive longer to suffer even more, probably for the sake of their egos or maybe because of the money involved. Who knows why exactly they are doing this.

[JessiekRN]

Since when is DNR the surgeon/attending's decision?? I'm a new RN but this seems completely out of line.. the patient/family have decided and the SURGEON has the right to veto that decision? Am I missing something?

[Purple_Scrubs, BSN, RN]

You absolutely did the right thing! This resident is following the medical model where the goal is to cure disease, regardless of the wishes of the patient and family.

Thank you for advocating for this patient!

[RN1982]

You followed policy. You advocated for your patient. It's the pigheaded resident that should be reamed out. Did you speak with your manager regarding the situation? And NO, they can't deny making someone a DNR/DNI if it's the family's wishes.

[WalkieTalkie, RN]

You followed policy. You advocated for your patient. It's the pigheaded resident that should be reamed out. Did you speak with your manager regarding the situation? And NO, they can't deny making someone a DNR/DNI if it's the family's wishes.

The manager was in a meeting this morning, but my charge nurse did let her know of the situation in case the surgery team tries to single me out and make it look like I did something wrong. I'm sure this isn't the last I will hear of this situation, but I am going to play it cool and act like I didn't do anything wrong -- because I didn't do anything wrong, I did the right thing, and I would hope another nurse would do the same in my situation.

We were taught to be patient advocates, and I will continue to be one, despite the fact that I was belittled by the resident this morning.

[Elvish, BSN, DNP, RN, NP]

I think you did exactly the right thing. It is your responsibility to be an advocate for the patient and her family....and this woman has every right to be made a DNR. She is obviously with it enough to mouth the words. And she does not deserve to be kept alive against her will.

We went through a similar situation when my grandmother was dying, though not nearly as involved. She was frail to begin with, then had a couple small heart attacks, which landed her in the hospital. She became septic from vegetation around her mitral valve, then of course weaker and weaker. It became pretty apparent to the family that she wasn't going to make it. Her medical doc was on board with letting her go, but the neurologist & pulmo were still wanting to run more tests to r/o Guillain-Barre (what!?!) My mother and her sibs had told the docs that Nana didn't want any more tests, she just wanted to be allowed to go.

What they ended up having to do was gather the whole crew in the room - my family, all her docs, and Nana -and my mom asked her, "Mom, do you want them to run more tests, or do you want to go?" As plain as day, Nana replied, "I want to go home and see Jesus!" She put more strength behind those words than she had any other since being hospitalized.

This may be what has to happen in you situation if it hasn't already. If these docs hear it (or see it, as the case may be) from the patient herself, they cannot ignore her. They cannot legally continue to resus her if they have seen her verbalize as an a&o adult that she doesn't want it.

My heart goes out to you, as you are in a tough spot. But you have done the right thing.

[Reno1978, BSN, RN]

Thank you for advocating this patient's and her family's wishes! I can't imagine how frustrating this must be for you and the family involved.

It's almost as though the doctors you were speaking with didn't understand DNR/DNI. If the justification for not writing the order was that she might get better in 3 months, that's a pointless reason. We're talking about an order that would handle the worst case scenario if she gets worse. If she has a DNR/DNI order written and does get better over the next 3 months, that'd be wonderful. However, if she goes into cardiac or respiratory failure, the patient definitely ought not be subjected to a code situation when it isn't her or her family's wishes.

[Neveranurseagain, RN]

Thank you for being such an advocate for your patients. America views death as failure and not the natural process it is. The medical community, as well as the general population, needs to be re educated on this subject. This problem is only going to get worse as us baby boomers grow older.

I would be honored to have you as my nurse. And this comes from someone who doesn't have a lot of trust in the medical system!

If this wasn't a case for the ethics committee then what is?

[nrsang97, BSN, RN]

Thank you for being such an advocate for your patients. America views death as failure and not the natural process it is. The medical community, as well as the general population, needs to be re educated on this subject. This problem is only going to get worse as us baby boomers grow older.

I would be honored to have you as my nurse. And this comes from someone who doesn't have a lot of trust in the medical system!

If this wasn't a case for the ethics committee then what is?

I was thinking the exact same thing.

[A_Simp]

I echo all the other poster's sentiments! However, if you fear possible retrobution by the resident make sure you document any "Harassment" and bring it to the attention of HR. As it can lead to a hostile work environment and put pt safety at risk.

[SuesquatchRN, BSN, RN]

You did the right thing and your nurse backed you up. SOmetimes you will have to stand up to little demigogues who think they know best - like this young resident.

Your boss backed you up and that's what matters.

Thank you for advocating for this helpless woman and her family. I'm proud to call you a colleague.