Had an interesting situation at hospital several years ago -
We had a 43yr old RN who admited to the hospital for elective inguinal surgery. He had no past medical or surgical history of significance except for depression which was controlled.(I think w/ celexia). No hx of psychosis or history of suicide attempts. He had been sober and active in AA for 22years with no remissions and stated his life was given back to him once.
He insisted on signing a DNR and was very clear if anything happened that he wished no rescue efforts -- NOT even medical interventions. The surgeon had a psych consult and he was found to be totally lucid and with controlled depression.
When asked why -- he had worked in ER for years and had seen and been involved in many codes. He felt that if there was a serious complication that he was totally ok with he passing. His family had no knowledge of his adamnt wishes. He also denied that he had any premonitions or feeling of impending death.
His primary care MD said that his wishes and right to make a descion, if an event occured, should totally respected. He said that since there was a psych clearance and he had non unreasonable explaination demonstrated t-- it ultimately was his right and privledge.
His surgeon refused to operate and he was discharged to seek care from another surgeon.
This caused a bit of controversy with the nurses on the surgical unit.
Have any of you had a similar case or even feel similar ? As always I am interested in your thoughts and opinions.
Marc
Ps I posted this by accident to another log please ingore other -- if you do submit a theat and want to delete it how is this done -- Thanks
Specializes in ER, NICU, NSY and some other stuff.
In my state DNR and advance directives are temporarliy rescinded during the perioperative period. This is on the surgical consents and must be signed for. It may have been that he refused to sign off on this with the surgical consent and this would be why the surgeon would refuse the surgery.
I understand his point of view regarding the DNR. I think I have similar feelings as this gentleman. I have told my hisband that I would not wish to be resusitated unless there is a 100% iron clad guarantee that I would be able to recover to 100%. I understand that this is not possible. but I too have worked ER too long and seen people brought back to exist in a nursing home contractured with a peg, and a trach, and a diaper....etc. I would not want to exist like this nor would I want my family encumbered with a situation like this.
Just why are we having people fill out living wills if we're not going to listen to them? There is no age restriction on being a DNR, and his family has nothing to do with his decision. We spend all this time educating patients that they have choices, and when a patient actually makes a choice he's questioned? He is an adult, cleared by psych. We are not here to second guess his choices. If the surgeon wasn't comfortable with this, then he can refuse to operate, which he did.
When asked why -- he had worked in ER for years and had seen and been involved in many codes.
His primary care MD said that his wishes and right to make a descion, if an event occured, should totally respected.
His surgeon refused to operate and he was discharged to seek care from another surgeon.
So he's 43, otherwise healthy and wants to be a DNR without his family knowing about it, right? Call me crazy, but I don't see a problem with it. I agree that he's really young to be making that decision. Yeah, this should be discussed with his family. But, he's mentally sound and it's his decision to make. Who here hasn't seen a pt who was healthy going into surgery have a bad outcome? How many of us have seen people who were *successfully* coded, but came back with some pretty serious deficits? Who are we to say that he (as a nurse who has surely witnessed both of the above outcomes) can't make that choice just because he's young or doesn't want the hassle telling his family would create?
It's all about playing the odds. He'd rather make his peace and pass away without the drama of a code than take the chance of spending the rest of his life unable to care for himself. Can't say that I blame him
Perhaps the man had a near death experience, "saw the place " where you go when you die, liked it, wanted to stay, but couldn't. Perhaps he doubts his ability to work and function as a nurse, providing for himself, if he came back at a 85% level. Perhaps anything less than 100% was not enough for him.
I completely understand the surgeon's refusal to operate on this man, and I understand the man's refusal to have the possiblity of accepting the possible role of an person who is unable to do his profession any longer.
Why is it okay for a person to decide to have an abortion without asking their family if it's okay, but it's not ok for a grown man to decide he doesn't want to be coded?
I would absolutely not want to be coded after lying in my driveway for a while with a broken neck after falling off the roof of my house (while cleaning the moss off) because I would rather not be a nursing home resident for the rest of my days.
I think I would like to be coded if I was in the hospital for a minor surgery.
But this decision should be mine, and not my family's. They don't have the right to have me sentenced to years as prisoner in a wheelchair, or a nursing home.
I think it is common practice at most hospitals for any DNR to be rescinded during any surgery for the time in OR and 24 hours post op due to the fact that following surgery there can be complications caused by anesthesia, blood loss, electrolyte imbalances in which once corrected the normal state of health of the patient returns. In the situation which a patient codes during or immediately after surgery and doesnt recover then the advance directive would be resumed and life support withdrawn which would still be following the patients wishes to not remain on life support.
I can totally understand the physician not wanting to perform surgery if it would put him in a position of not being able to fully treat the patient while on the OR table.
I do agree it is 100% the patients decision to make and if he chooses to not involve his family that is also his choice. There are many reasons why he may not want his family involved and we dont know what the family dynamics involved are however I also understand that once a patient is no longer able to make his own decision then any previous written advance directive is thrown out the window and it becomes the next of kins decision therefore it would be wise for anyone to have someone they trust to follow their wishes as power of attorney. My grandmother was a case in point--she made it perfectly clear to all of her family and also had a prewritten advance directive prior to her getting sick which stated she wanted to be a DNR with no heroic measures/life support. She was in the hospital and in her right state of mind upon admission and there was a order for DNR on the chart and also a copy of her advance directives however has her condition worsened and she became more lethargic/confused and eventually went into respiratory failure one of her 3 children disagreed with her advance directive decision and told the doctor that she wanted "everything done". Her other 2 children wanted to follow her wishes however the doctor went ahead and intubated my grandmother with the explaination that he had to follow the family's wishes once my grandmother became incapicated and until all 3 of her children could agree it was easier to withdraw life support then to "bring back the dead". I guess what Im trying to say is that even with a DNR/advance directive it is still possible and I've seen it happen personally as well as professionally that a family member will override the decision once the patient becomes incapicated therefore it is always best to have a power of attorney that you know will follow your wishes.
-once a patient is no longer able to make his own decision then any previous written advance directive is thrown out the window and it becomes the next of kins decision
-advance directive prior to her getting sick which stated she wanted to be a DNR with no heroic measures/life support.
Wow...first off, sorry to hear about your grandma It's always harder to lose someone close when there is family drama involved.
That said, who gave the docs the right to decide that after she can't speak for herself her DNR doesn't count?????:angryfire The reason people make living wills and sign DNRs is to avoid being put on a vent while their family dukes it out. Why did the doc completely disregard her wishes? In my hospital at least, advance directives ALWAYS trump family. We still get the nasty "let him go" "NO! do everything to save him" stuff in the absence of DNRs, but that is a legally binding document in my state and unless the patient tells us they changed their mind it's followed. Too bad other places get away with ignoring what a competent adult has decided they want done in their final days:uhoh3:
I guess I'm not really understanding where the controversy is. I have a feeling that the real issue is that nurses/doctors don't feel like the patient should be making such a decision. But once he's been cleared by psych, I think the controversy should be resolved. As for thinking that his family should be informed about this, why? I would feel a responsibility to my husband to inform him of health care decisions, but it isn't my place to enforce my sense of responsibility on someone else who obviously doesn't feel that way. Perhaps he feels like it's none of their business. Perhaps they haven't been close, etc.
I'm not fond of families being given the right to weigh in on an individual members care. I've heard all to often about families overturning a DNR on their 89 year old grandmother, not wanting her to die at any cost. So does the individual truly have a choice in their health care decisions, or only until a family member changes their mind? I say leave the family out of it and abide by the patients wishes.
I would also respect the surgeons choice to not do the surgery, that is his right as well.
-once a patient is no longer able to make his own decision then any previous written advance directive is thrown out the window and it becomes the next of kins decision
-advance directive prior to her getting sick which stated she wanted to be a DNR with no heroic measures/life support.
Wow...first off, sorry to hear about your grandma It's always harder to lose someone close when there is family drama involved.
That said, who gave the docs the right to decide that after she can't speak for herself her DNR doesn't count?????:angryfire The reason people make living wills and sign DNRs is to avoid being put on a vent while their family dukes it out. Why did the doc completely disregard her wishes? In my hospital at least, advance directives ALWAYS trump family. We still get the nasty "let him go" "NO! do everything to save him" stuff in the absence of DNRs, but that is a legally binding document in my state and unless the patient tells us they changed their mind it's followed. Too bad other places get away with ignoring what a competent adult has decided they want done in their final days:uhoh3:
again, in the absence of a major illness, it's just not natural for a 43 yo to request dnr.
it just doesn't make sense.
maybe he interprets a code as a 'calling' from the Higher Power?
maybe he truly is depressed but is not letting on?
i do understand his rights.
i just don't understand why.
leslie
There's nothing necessarily un-natural about it. We don't know this man's cultural or religious beliefs. It may well be in line with those aspects of his life that he choose DNR.
I am perfectly healthy, and yet I am a DNR as well. No medical interventions. Not everyone feels they must cling to life desperately if something goes wrong. Fighting the natural course does not come naturally to everyone.
Specializes in Education, Acute, Med/Surg, Tele, etc.
This is a toughie! However...do the rules that govern DNR status state: only if you are over the age of __, and/or have a serious illness, and/or have family approval? NOPE! This is a individual choice in his case between him and a Physician...and it is well within his rights to decline CPR or heroic efforts if he was to code.
Yeah but I sure wish my hubby would discuss this with me before hand for sure! It isn't just HIM involved in the aftermath of that! I find that to be selfish in a large way not to involve his loved ones in that choice.
I don't blame the surgeon for saying "not touching that with a ten foot pole!"...I wouldn't either. Even though as I said he is within his rights...it is also within a Physicians rights not to put his job on the line like that and decline his service with that patient.
Specializes in Clinical Research, Outpt Women's Health.
He had the right to invoke the DNR because he was found to be legally competent, the surgeon had thre right to refuse to do surgery. Doesn't sound contreversial to me at all.
It's always harder to lose someone close when there is family drama involved. 
babynurselsa, RN
1,129 Posts
In my state DNR and advance directives are temporarliy rescinded during the perioperative period. This is on the surgical consents and must be signed for. It may have been that he refused to sign off on this with the surgical consent and this would be why the surgeon would refuse the surgery.
I understand his point of view regarding the DNR. I think I have similar feelings as this gentleman. I have told my hisband that I would not wish to be resusitated unless there is a 100% iron clad guarantee that I would be able to recover to 100%. I understand that this is not possible. but I too have worked ER too long and seen people brought back to exist in a nursing home contractured with a peg, and a trach, and a diaper....etc. I would not want to exist like this nor would I want my family encumbered with a situation like this.