Why don't med staff follow advanced directives?

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Specializes in ICU.

In school, we are trained that advanced directives are legal documents to be followed by doctors and nurses. Why is the next of kin allowed to change a pt's DNR status at the last minute? Why can they prolong care when the pt's living will states otherwise, and the pt is unable to object? All I can reason, is that it is a legal issue--that the family is alive and able to sue when the pt is incapacitated. I feel like this is wrong and that it causes pt's unwanted suffering. Does this happen everywhere?

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Specializes in LTC,Hospice/palliative care,acute care.

I belive it varies from state to state.Advance directives are open to interpretation.Look up some of the forms available on the web.Most patients state they want heroic treatment with held if they have no chance of a meaningful recovery.When the patient is incapable of speaking for themselves the doctor just has to say "We aren't there yet" and keep them going and going.I've seen fellow nurses agree to feeding tubes and intubation directly against their parent's wishes because some physician brow beat them with things like "You can't let your dad starve" or "Your mom needs some rest-lets give her 24 hours on the vent" I've also seen docs approach elderly patients circling the drain-people with clear advance directives-and talk them into feeding tubes and vents.If I'm on my death bed and I have made my wishes known don't ask me over and over ..."Do you want a tube-you are going to starve without it" because I could say anything at that time.Unethical but common around our LTC.

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It is not a legal document to the point where it has to be followed. It is simply a document that lists the pt's wishes. They used to have to be notarized, that was just to say that the person filling out the document is indeed the one who signed it, etc.

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Specializes in icu, er, transplant, case management, ps.

I have both a Living Will and a Health Care Proxy. My daughter and I have discussed my Living Will and she understands what I wish and when I want my wishes to be carried out. I have also talked with my PCP about my directives and have gotten his agreement to abide by my wishes.

And I have threatened my daughter and PCP that if they do not follow my directions, when I finally do die, I will come back, and haunt the heck out of them. And they both know, I keep my word.

Woody:balloons:

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Specializes in ICU, ER.

it is a legal issue--that the family is alive and able to sue when the pt is incapacitated.

That's part of the problem. Also, many staff forget that a living will is not an automatic no-cpr order. It is only valid when the pt's condition is terminal.

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Specializes in icu, er, transplant, case management, ps.
That's part of the problem. Also, many staff forget that a living will is not an automatic no-cpr order. It is only valid when the pt's condition is terminal.

Actually, a Living Will expresses only the patient's wishes. It has no legal standing. And if a family member, who has the right, can sue if the wishes are carried out and they were against them. A Health Care Proxy is a legal document. It appoints someone to make decisions when a patient is incapable of making them. And the signature has to be witnessed by two non-interested witnesses. And it lays out the conditions under which a patient no longer desires that anything be done to them. And the patient does not need to be at death's door, for their health care proxy to carry out the individual's directives.

There are circumstances that a health care proxy does not necessarily have to be follow. Among them are the fact that the person appointment is not a family member or a member of the legal profession. In many states. S.O.'s have no legal standing, even when name, if he/she is a member of the same sex.

Also, a health care proxy does not necessarily have any legal standing, if the PCP treating does not agree or the hospital does not agree. If a close family member is against it. And there have been cases where this has happened.

Mine states that I am not to have CPR or entubation done if:

1. I have had three serial EEG, showing minimal brain activity

2. That I am most likely to live in a vegetative state.

3. If I suffer a permanent spinal cord injury.

4. If I suffer a massive head injury

5. I do not wish feeding tubes to be inserted.

It is for these reasons that an person needs to let family members, their physician, their proxy.

This being said, I hope to die, in my sleep, at home, in my bed. And be found the next morning. This way there can be no chance of anything be done against my expressed wishes.

Woody:balloons:

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actually, a living will expresses only the patient's wishes. it has no legal standing. and if a family member, who has the right, can sue if the wishes are carried out and they were against them. a health care proxy is a legal document. it appoints someone to make decisions when a patient is incapable of making them. and the signature has to be witnessed by two non-interested witnesses. and it lays out the conditions under which a patient no longer desires that anything be done to them. and the patient does not need to be at death's door, for their health care proxy to carry out the individual's directives.

there are circumstances that a health care proxy does not necessarily have to be follow. among them are the fact that the person appointment is not a family member or a member of the legal profession. in many states. s.o.'s have no legal standing, even when name, if he/she is a member of the same sex.

also, a health care proxy does not necessarily have any legal standing, if the pcp treating does not agree or the hospital does not agree. if a close family member is against it. and there have been cases where this has happened.

mine states that i am not to have cpr or entubation done if:

1. i have had three serial eeg, showing minimal brain activity

2. that i am most likely to live in a vegetative state.

3. if i suffer a permanent spinal cord injury.

4. if i suffer a massive head injury

5. i do not wish feeding tubes to be inserted.

it is for these reasons that an person needs to let family members, their physician, their proxy.[/b]

*staggering back in shock*

oh my......a subject that woody and i actually agree upon!!!!!

teasing, woody, really.....you have to admit that the fur has flown between us lately, and it's nice to find something that we see eye to eye on.

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Specializes in icu, er, transplant, case management, ps.
actually, a living will expresses only the patient's wishes. it has no legal standing. and if a family member, who has the right, can sue if the wishes are carried out and they were against them. a health care proxy is a legal document. it appoints someone to make decisions when a patient is incapable of making them. and the signature has to be witnessed by two non-interested witnesses. and it lays out the conditions under which a patient no longer desires that anything be done to them. and the patient does not need to be at death's door, for their health care proxy to carry out the individual's directives.

there are circumstances that a health care proxy does not necessarily have to be follow. among them are the fact that the person appointment is not a family member or a member of the legal profession. in many states. s.o.'s have no legal standing, even when name, if he/she is a member of the same sex.

also, a health care proxy does not necessarily have any legal standing, if the pcp treating does not agree or the hospital does not agree. if a close family member is against it. and there have been cases where this has happened.

mine states that i am not to have cpr or entubation done if:

1. i have had three serial eeg, showing minimal brain activity

2. that i am most likely to live in a vegetative state.

3. if i suffer a permanent spinal cord injury.

4. if i suffer a massive head injury

5. i do not wish feeding tubes to be inserted.

it is for these reasons that an person needs to let family members, their physician, their proxy.[/b]

*staggering back in shock*

oh my......a subject that woody and i actually agree upon!!!!!

teasing, woody, really.....you have to admit that the fur has flown between us lately, and it's nice to find something that we see eye to eye on.

as i am getting older, i have become afraid of what modern medicine can do to me, in the effort to save my life. i remember, when i was much younger, swearing to have dnr tattoo on my chest. now i have a living will and a health care proxy, and i am still afraid. i fear that i will end up in a hospital, where they will ignore my wishes, ignore my proxy, and keep me suffering and alive.

and yes, this is a topic we agree on. too many times i have seen patients suffer because a family member does not want to let go. or a physician cannot admit defeat. i remember when my uncle was hospitalized with ca of the lung. he didn't stand a chance of living, yet the nursing and house staff would refuse to give him pain medication because he couldn't ask for it. when we met with them, as a family, they were going to refuse to follow our instructions about a dnr, telling us that it was against hospital policy and against nys law. they didn't realize that i had worked for the department of health and was currently an administrative

assistant at downstate, a state operated acute care hospital. i asked for a separate meeting, told them they were full of bull. and if they didn't make him a dnr, i would get in touch with the commissioner of health. they didn't believe me. so i want to the public telephone, called him at home, told him what was going on. he asked to speak to the senior resident. we got our dnr and my uncle die several days later. it scared the bee jess out of me, that they could do that. i often wondered what happen to patients and families that did not have the connects i did. i am certain that they suffered.

woody:balloons:

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Specializes in Med-Surg/Tele, ER.

This factor really bums me out on the floor where I work, and it comes up all the time because we work with a lot of older pts in the final stages of disease processes. We had one lady who had explicit DNR/I instructions, was terminal with Ca and really suffering. When she coded her family couldn't handle it and demanded CPR and all lifesaving measures be initiated. She actually did wake-up in the ICU after that, and she was understandably LIVID.

I like to think I wouldn't put my family member through that, but people do all sorts of crazy things when they are experiencing extreme grief. I mostly feel for the patient, their bodies are the ones being tortured after all, but I try to understand the family. I try.

I think another issue is people have really unrealistic expectations of what CPR, intubation, vasopressors, etc can actually do for a person. They think if a heartbeat is re-initiated the person will wake-up and be just as before (like on "ER" or "House" or whatever). I think a lot of people also don't understand what the odds are for a person to "come back" after a code, especially an elderly or very sick person, and there certainly is very little understanding as to the complications which arise after a pt does.

I don't know how many pts and pt family members I have spoken with who initiate a conversation like "Oh, he died, but they brought him back. Then he had a stroke ... and pneumonia ... and X, Y, Z...", and they are so surprised this occurred with so many complications.

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