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Discussion

What would you Do?

You work in a nursing home and recently admitted a patient in end stage AIDS from a hospital after a 2 month stay. He was treated with over a 100 units of PRBC and FFP. The attending didn't think he would survive this stay. During admission, he is AAOx3 ,he and his wife wanted full code.two weeks later, he started bleeding profusely. You called the doctor to get an order for a transfer and he said. "I won't give you an order for transfer because it is a total waste of resources" then hung up.

What would you do as a primary nurse?

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    • Featured Replies

    The patient and next of kin have indicated that he is to be a full code. This should be documented in the patients chart. I would send him to the hospital anyway, and let the Dr. explain later why he was willing to go against the patients designated code status. It's not the Dr.'s place to allocate "resources".

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    A. Document it. B. Call my DON. C. Document it. I'm not sure beyond that...depends on if the patient is already on Hospice or not...

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    Call your DON, let the higher-ups deal with it.

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    • Experts

    If the pt is actively bleeding:

    1. Call 911

    2. Call MD

    3. Call DON

    Patient care ALWAYS comes first.

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    Kick his figurative ass. I may have tried calling him back, and if he refuses still, its time to move up the chain of command - start with your DON (unless, natch, the patient was actively bleeding at the moment, in which case, call 911, screw the transfer).

    You can't deny a patient based on your opinion about resources (similar to EMTALA). He is a full code, and you have an obligation to do what is best for the life of the patient, even when they are end stage (assuming this is what the patient wants, which his code would indicate).

    If he is going to insist on this refusal, it would be duty to come to the patient and discuss what appears to be essentially a termination of his duty to the patient.

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    I would call the MD back and say "I just want to make certain that I am quoting you correctly in charting your order that the patient is to be denied a transfer because it is a waste of resources. Is that correct Doctor?" I would expect some very fast backpedaling from said MD. (As he visualizes THAT in court). However, realize in doing this that you can also expect to be yelled at, written up, possibly disciplined (if administration prefers to kiss up to docs) and possibly fired. I've only ever had to go to this extreme twice and it had the desired effect both times, though not without repercussions.

    Next step would be to call supervisor, administrator, ethics committee representative, the hospital's legal person - generally stir up a hornet's nest.

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    • Experts

    I agree with Traumarus

    1) CALL 911

    2) call the wife

    3) CALL MD and tell him the patient is at the hospital.

    4) CALL the DON.

    The patient always comes first and you can be sued for not calling 911.....

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    1. 911

    2. DON

    3. Wife

    4. MD to notify

    5. Document entire event with as many direct quotes as you can remember.

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    What is the policy regarding medical decisions on your facility? We have a type of edict in place about "medical futility"....whether or not the family wants full code, the doctor can override it. BUT..he has to make a new CMO status and begin a type of hospice care...it's only fair to the patient to keep him from suffering.

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