Violating a Code Status...

[Haunted]

An elderly female patient was admitted to the hospital with anemia, R/O GI bleed, dehydrated, c/o pain to right jaw. Admit orders were NPO, type and cross pending H and H, MRI/CT of jaw, rule out infection, d5 1/2 at 75 cc, resume current meds, mostly for DM and mild hypotension, coumadin and synthroid, pain meds ordered and place on telemetry. VS stable upon admit, patient a, a and o x 5, pain is under control. So far so good. Within 3 days she is diagnosed with Parotitis right jaw, transfuse 2 units RBC, place picc line, dc home for daily atb infusion. OK, moved to step down unit....

Day of this incident she is seen by nurse, signed consent for radiology procedure, returned at 1000, some bleeding at site but tolerated well. Spouse at bedside, patient ambulatory and requesting assist with a shower.

Nurse returns at 1210 to discover patient alone, laying on her side in bed, cyanotic, apneic, non responsive, no pulse, calls a code, which per notes happens over 12 minutes before they are able to establish both an airway and a pulse. She is transferred to ICU on vent, BP meds and ativan due to mild seizure activity. Family is notified.

2 days later, despite being on prednisone, intubated, removed from Versed for exam, neuro consult is very grim. Patient has gag reflex, dolls eyes, mild seizures and slowed brain wave activity. Patient is also at this time receiving Glucerna thru oral intubation as midline cath has infiltrated so emesis with positive CRX for fluid aspirate.

Now, upon review of this patients chart, an advance directive is found in the back which the patient and her husband had executed less then 2 years ago, both had checked off "If in the even I am found uncounscious, my condition will not improve or I am faced with artificial life support, including ventilators and advanced cardiac life support, I hereby decline and wish to advance towards a natural death without these measures". It was also in her admitting docs office charts and on file with this hospital.

It was not, however anywhere in her Kardex, anywhere in her admit notes, transfer notes or during a 24 hour chart check. 6 days she was being treated for this infection and no one saw this, nor was it mentioned. Someone finally did though, she was extubated on a Friday evening, given comfort measures, transferred to a med floor and finally passed away early on a Sunday morning.

Now, I guess we all know whom I am am taking about so issue is out of the way, but never in my years of nursing, even while covering for another nurse talking a bathroom break, lunch break, whatever, not know the code status of a patient. I have grieved and felt saddened by the loss of patients, have seen the tears, disbelief and sorrow at a loved ones passing but I always knew the code status and would never subject a patient to something they had gone out of their way to make sure would never happen to them.

People spend thousands of duckets on advance directives, wills and testiments and I am scared 3 shades of psycho to think it could be so blatently (is that conceivable) overlooked in such a way.

Well, in conclusion, always, always know your patients code status and keep your fellow nurses informed. No one should have to go thru this, especially a patient. What do ya say ?

[TazziRN, RN]

Nobody's perfect. Yes, her advance directive should have been honored, but it was missed. Better to miss an advanced directive and code a pt, than assume a pt is DNR and not code.

[pebbles, BSN, RN]

I've seen people coded by mistake. It happens. Most of what I've seen is the same as you describe - it was just missed in the chart. One time there was a DNR order on the first page of the orders, but the "admission" orders were on the next page. So the DNR order never got transcribed, and the nurse must not have seen it. I agree with the above poster - better to err on the side of calling a code than the other way round.

The family can still choose to withdraw treatment and let her go as per her wishes if the ICU facilitates it. If she is on a vent, often just extubating will cause them to slowly pass away.

[arpeggiated]

One of our docs constantly puts that his pts are DNR status on the H&P when he dictates. I see it, I go look in the chart, and he's ordered full code.

Sweetest man alive, but really. He does have a lot of older and nursing home patients who are DNRs, but not all of them.

[luvpeplrn]

I would rather code a DNR, than not code a Full Code. If the world were perfect this would never happen, but nurses are so overloaded this is almost understandable.

[nursingisworkRN]

In my hospital, unless you have a DNR order from an md (or residents with renewal w/in 24 hours by md), your pt is a "full code". No md order=full code. Good nursing practice is to find out pt/family wishes and facilitate. This often is overlooked. It is unclear what the family thinks about the events, but I would think that if you hadn't coded her and the family was upset, you would have had a hard time in court without a DNR order from Md. I know when we have DNR pts that are transported out of hosptial in ambulance to another facility, we still need a "DNR during transport" order even when the pt has an advanced directive.

That being said, I am sorry that you are faced with this ethical dilemma. At the time, the nurse on duty was trying to protect the pt's life and well being. Now the family will be instrumental in implementing the pt's wishes. I guess this is a great example of being proactive in knowing pt's wishes before they turn for the worse, ideally upon admission.

[EmmaG, RN]

Now, upon review of this patients chart, an advance directive is found in the back which the patient and her husband had executed less then 2 years ago, both had checked off "If in the even I am found uncounscious, my condition will not improve or I am faced with artificial life support, including ventilators and advanced cardiac life support, I hereby decline and wish to advance towards a natural death without these measures". It was also in her admitting docs office charts and on file with this hospital.

Am I missing something here? There was an advance directive, but no DNR order from the doctor? If that is the case, the patient is a full code until that order is written, regardless of the directive.

The VA advance directive form states "If at any time my attending physician should determine..."

http://www.thearcofnova.org/docs/directiveForm.pdf

It's up to the doc to make that call and honor their wishes.

[EmmaG, RN]

In my hospital, unless you have a DNR order from an md (or residents with renewal w/in 24 hours by md), your pt is a "full code". No md order=full code. Good nursing practice is to find out pt/family wishes and facilitate. This often is overlooked. It is unclear what the family thinks about the events, but I would think that if you hadn't coded her and the family was upset, you would have had a hard time in court without a DNR order from Md. I know when we have DNR pts that are transported out of hosptial in ambulance to another facility, we still need a "DNR during transport" order even when the pt has an advanced directive.

That being said, I am sorry that you are faced with this ethical dilemma. At the time, the nurse on duty was trying to protect the pt's life and well being. Now the family will be instrumental in implementing the pt's wishes. I guess this is a great example of being proactive in knowing pt's wishes before they turn for the worse, ideally upon admission.

I see we posted the same thing at the same time lol.

Now here's a sticky situation I've found myself in more than once... a "no code" patient (who has made their wishes crystal clear) is actively dying, unable to communicate with us, and their DPA demands they be coded. Sad to say, we've done so.

[Dixielee, BSN, RN]

Please correct me if I am wrong, but I thought the advanced directive was simply a means to notify all of a patients wishes, but is not a legally binding agreement. The physician still must write a DNR for it to be "legal".

In any case, in our hospital, we have preprinted orders for every specialty including general medical. Every one of these orders starts with places for Admission physician, diagnosis and code status at the very top.

It is much easier this way, and you don't have to guess. Sorry you had to go thru what you did, but that sort of thing happens more often than you would think. We have people come in frequently from nursing homes who have active, signed DNR's who are near death or cardiac arrest, and CPR, airway management, etc. has been initiated. We generally terminate the code quickly when we realize it, but usually not until the physician speaks with the family to give them the status.

The worst case I ever worked with was a young woman with end stage breast cancer and an active DNR on the chart. She stopped breathing, the husband insisted all measures be initiated, so she was coded, intubated and brought to our ICU. She came around rather quickly and was extubated, only to be mad as heck at her husband and the hospital staff. She stabalized and was transfered out of the unit, so I don't know what happened after that, but she was so upset, alternating between sobbing and screaming. It was awful.

We are many times caught in a Catch 22 between written requests and family intervention. We only hope we do the right thing, and sometimes we never know what that might be.

[EmmaG, RN]

Took care of a dear lady once, dying of met colon CA. She was a no-code, comfort measures only. Her daughter stayed at her bedside day and night, and called me down to her room telling me "Mom is going now."

As I stood there with her, holding her Mom's hand and watching her take her last breaths, daughter turns to me and calmly asks, "Do you have to wait until she stops breathing to do CPR?"

!!

I gathered myself as best I could, explained that her mother was a DNR and that we would allow her to pass away.

"Oh no. I want everything done."

*sigh*

[TazziRN, RN]

Took care of a dear lady once, dying of met colon CA. She was a no-code, comfort measures only. Her daughter stayed at her bedside day and night, and called me down to her room telling me "Mom is going now."

As I stood there with her, holding her Mom's hand and watching her take her last breaths, daughter turns to me and calmly asks, "Do you have to wait until she stops breathing to do CPR?"

!!

I gathered myself as best I could, explained that her mother was a DNR and that we would allow her to pass away.

"Oh no. I want everything done."

*sigh*

Now that is so sad.....

[kcalohagirl]

Took care of a dear lady once, dying of met colon CA. She was a no-code, comfort measures only. Her daughter stayed at her bedside day and night, and called me down to her room telling me "Mom is going now."

As I stood there with her, holding her Mom's hand and watching her take her last breaths, daughter turns to me and calmly asks, "Do you have to wait until she stops breathing to do CPR?"

!!

I gathered myself as best I could, explained that her mother was a DNR and that we would allow her to pass away.

"Oh no. I want everything done."

*sigh*

That makes me die inside a little. My parents are the type of people who would keep me alive on tube feedings even were I totally brain dead. They are also the type who would try to get around any advance directive I might have. I am so incredibly thankful my husband (also a nurse) and I have the same views.

However I can't believe my parents (at the age of 70+) still don't have advance directives. And they have extensive histories! All I can do is encourage them, I can't exactly hold a gun to their head and force them to do it.