Revived when there was a DNR/AND code status

[ambersky004]

There was this experience that I will never forget in my nursing career.

Patient N came back with Afib with RVR. She converted to SR during shift change. The night nurse said she had episodes of chest pain. From her report she said the Pt N was more anxious that night. Pt N told the attending doc she wanted to go home and if she die of a heart attack she is fine with it. Her code status was DNR/AND. The heart doc said she needs stress test or cardiac cath but she's been refusing the cath the last time she was in our unit. I told the hospitalist she has been talking about her dead sister this morning and she wanted to "visit her?" She was teary-eyed. She denies any chest pain except last night. She denies any depression or thoughts of suicide to the attending doc.

So the attending doc told her the plan is she can go home with an outpatient stress test. Her 3 Troponins where elevated but trending down. Her series EKGs shows she had a previous MI and afib. WHile I was discharging another patient and educating her family and answering there questions, I saw our CNA wheeling our crash cart. So I look where he is going and I saw staff in a room. It is weird I did not hear the rapid response called. So I went and saw the RT doing CPR and ambu bagging. Our on call doc was in room and I told him she is a DNR. I saw the V-fib on the heart monitor and the heart doc asked me a question and told him she came in with Afib RVR. He asked me who is the doc I told him the heart doc but forgot she was not on duty that day so he said to call her and asked what she wanted to do.

So I called her and she said she will be right there. When I came back pt's attending doc was in there now and told them and the on call heart doc she is a DNR but she was defibrillated anyway or they still defibrillate her. The patient woke up and was a little upset, she was telling me, "that was my time." Or maybe because she fell unconscious and she might still be in a fog. I feel so guilty. I felt like i missed something like putting the DNR armband. Maybe that would change the doc's and team members intervention since I was not there immediately in the room. I swear i did not hear the overhead call. The attending doc was telling me, she's going to be pissed. So I scratch my head and the heart doc laughed at me, I think 'coz he looked me in the face but i was so shooked up it happened so fast 'coz the attending doc just talked to her that time and I just rounded her. Lastly, the patient is alive and agreed to get a cardiac cath.

In regards to ethical issue and patient's wish during hospital stay, did we break her code status? Will there be an issue? I always thought that atleast try to revive the patient when there is a chance. And probably that was the heart doc's thinking but the attending doc was on the patient's side. Ughhhh. What should I do the next time i encounter this situation? I know the patient is well-knowledgeable of her condition and her risks.

[Kyrshamarks, BSN, RN]

Actually in most states, healthcare workers cannot be sued for not following a dnr. Furthermore the standard is when CPR is initiated on a pt you do not stop if it is discovered they are dnr. You are obligated to finish the code.

[MunoRN, RN]

Actually in most states, healthcare workers cannot be sued for not following a dnr. Furthermore the standard is when CPR is initiated on a pt you do not stop if it is discovered they are dnr. You are obligated to finish the code.

There aren't any states where healthcare workers are protected by refusing to follow a competent patient's refusal of treatment, and that can actually fall under the realm of a criminal act. If it is discovered during the course of code that a patient does not want that intervention, then continuing the code could potentially be prosecuted as battery.

[ambersky004, BSN, RN]

There aren't any states where healthcare workers are protected by refusing to follow a competent patient's refusal of treatment, and that can actually fall under the realm of a criminal act. If it is discovered during the course of code that a patient does not want that intervention, then continuing the code could potentially be prosecuted as battery.

What if the patient did not have any complications following survival? She consented to get a cardiac cath the next day.

[ambersky004, BSN, RN]

Actually in most states, healthcare workers cannot be sued for not following a dnr. Furthermore the standard is when CPR is initiated on a pt you do not stop if it is discovered they are dnr. You are obligated to finish the code.

I might look at our hospital policy regarding this. Thank You.

[JKL33]

Furthermore the standard is when CPR is initiated on a pt you do not stop if it is discovered they are dnr. You are obligated to finish the code.

That is not true.

[JKL33]

What if the patient did not have any complications following survival? She consented to get a cardiac cath the next day.

We can't just do whatever we want to do, totally disregarding the patient's autonomy as long as we don't cause any complications.

That said, I don't see where you really have anything to do with this. If I were you I would not take responsibility for others' actions and decisions. You may have caused yourself a bit of a problem by not documenting your stance and your advocacy of the patient's wishes, though.

[MunoRN, RN]

What if the patient did not have any complications following survival? She consented to get a cardiac cath the next day.

I'm not sure the fact that she later consented to a different medical treatment really affects the issue with her code status not being clearly communicated. There were clearly issues with the overall process for communicating pateints' code status in the scenario you've described, and it's a little concerning that the MD did not honor the patient's initial refusal of various tests and treatments, which might explain why the MD didn't adequately communicate the patients declination of resuscitative treatments.

[ambersky004, BSN, RN]

We can't just do whatever we want to do, totally disregarding the patient's autonomy as long as we don't cause any complications.

That said, I don't see where you really have anything to do with this. If I were you I would not take responsibility for others' actions and decisions. You may have caused yourself a bit of a problem by not documenting your stance and your advocacy of the patient's wishes, though.

You have a point. I break the pt's advocacy. I was thinking about why i didn't yell at the doctor or in the whole room to hear me. I told him she is a DNR but told me to call the doc. So the hospitalist came and she also said she is a DNR. The hospitalist did covered her butt and I did not cover my own butt. That was frustrating too.

[guest940422]

I would let risk management know, document you advised against cardioversion in the code sheet, and request a debriefing of the code. Doing a root cause analysis of how the code status was disregarded (without pointing fingers) can keep it from happening again.

We are human, we make mistakes, this is why healthcare will never be perfect. Most doctors, when unsure, would rather get reprimanded for saving a patient who didn't want to be, than failing to save someone who did (or who's family did).

I've worked at a lot of places who put a laminated heart or some other sign on the door and over the bed that visitors won't recognise but the staff knows means the pt is an AND. We also don't usually have them on monitors. If they are a partial code there is a neon binder at the foot of the bed (you can't miss it) with the advance directives.

But our code status's get overturned a lot in PICU, parents think they have made their decision until their child is actually actively dying, when they see them lose consciousness, they change their minds a lot. All it takes is a verbal retraction and }POOF{ get the crash cart.

I've never been in a situation where a pedi patient was revived against the family's wishes.... all the signage is mostly to keep out unnecessary staff to give the family privacy.

[inthecosmos, BSN, MSN, RN, APRN]

What if the patient did not have any complications following survival? She consented to get a cardiac cath the next day.

It does NOT matter what she consented to AFTER you failed to adhere to her wishes. DNR's are legal documents and unless it was a HCPOA or the patient themselves requesting to revoke the DNR, the staff here FAILED the patient.

If you told to DR that she was a DNR and they decided to continue with the code, then document that. You should not have went home without doing that. Documenting this far after the incident may come off as a lie or false documentation.

Risk management should be involved.

I wish you luck.

[Farawyn]

You have a point. I break the pt's advocacy. I was thinking about why i didn't yell at the doctor or in the whole room to hear me. I told him she is a DNR but told me to call the doc. So the hospitalist came and she also said she is a DNR. The hospitalist did covered her butt and I did not cover my own butt. That was frustrating too.

I yelled at the nurses over the phone at the nursng home to stop coding my Dad, and they didn't. If he had lived, I would have sued their asses off.

Thank God he didn't.

And yes, that sounds horrible.

[Crush]

Absolutely a case for risk management involvement.