witnessing a DNR

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Specializes in ER, progressive care.

We had a patient who was actively dying. The MD spoke with the family and they were deciding whether or not to make this patient a DNR. I went into the patient's room with the primary RN to see the patient; their eyes were glazed over and they were agonal breathing. The patient's extremities were warm but after some time the primary RN & I noticed that they were starting to cool down and the patient started turning pale.

The decision was made to make this patient a DNR. Now we needed witnesses; we had some family members on the unit. I had a patient with a family member in the room, so i decided to ask them. The family member was already sort of awake and I politely explained to them that we have a patient just down the hall and there was a decision to make them a DNR but we needed two witnesses. The witnesses had to be unrelated to the patient/family members and they could not be employees of the hospital.

I told the family member they weren't obligated to be a witness if they didn't want to. The family member said to me, "Oh, but I was sleeping so good, and I don't think I can make it to the room...where is it?" "Just across the hall." "Oh ok, but I don't think I could make it...." and I reminded them they didn't have to be a witness if they didn't want to, and it sounded like they didn't want to do it. Then they started talking about all sorts of other random things before finally (reluctantly) agreeing to witness.

The primary RN was standing in the hall trying to usher me out and I was trying to speed things along...I really wanted to just tell this family member, "the patient is ACTIVELY DYING and if we don't get this DNR signed SOON, we may have a full code on our hands and that would be against the wishes of the family." I then realized that could be a HIPAA violation, so I kept my mouth shut.

We finally arrived to the outside of the patient's room and almost immediately the family member said, "Oh you don't need me" and started walking back, but I told them we needed TWO witnesses, unless of course now they are not agreeing to witness. They reluctantly stayed, signed the paper and then I escorted them back to their room.

It was not like I was trying to twist this family member's arm into witnessing this DNR, but it sure felt like it. In the past I have asked visitors to witness a DNR and they have all immediately agreed to it. I don't know, I was just annoyed by it and I wanted to get this off my chest, I guess! Sorry it was long. Thanks for reading.

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Specializes in Gerontology.

Sounds like a crazy policy to me. What do you do if you can't get visitors to agree to be witnesses? And it does seem like you we're twisting this one Preston's arm to get them to do it.

Code status is something that should be discussed long before the pt is almost dead.

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Specializes in ER, progressive care.
Sounds like a crazy policy to me. What do you do if you can't get visitors to agree to be witnesses? And it does seem like you we're twisting this one Preston's arm to get them to do it.

Code status is something that should be discussed long before the pt is almost dead.

This patient used to be a DNR, then they were agreed to be a full code (WHY, I'm not entirely sure)...then once the MD told the family the patient was not doing well, it was agreed to make the patient a DNR again. :facepalm:

That is a good question. I'm guessing it is not like that everywhere? I always thought witnesses were needed for a DNR...whether or not the patient is fit to sign.

And no, I wasn't trying to twist their arm. I just asked, the family member was dilly dallying and I told them they didn't have to agree, we can find someone else...they continued to dilly dally then agreed. In no way was I twisting their arm or trying to force them to be a witness. Basically, I just wanted a simple yes or no from this family member.

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Specializes in NICU.

We don't "consent" family for DNR status. The family and the physician/team have a conversation, then the physician writes the order.

What your facility is forcing you to do is really inappropriate. Why can't hospital employees witness the signature? They do for other things like surgical consent and blood product consent.

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Specializes in ER, progressive care.
We don't "consent" family for DNR status. The family and the physician/team have a conversation, then the physician writes the order.

What your facility is forcing you to do is really inappropriate. Why can't hospital employees witness the signature? They do for other things like surgical consent and blood product consent.

I'm not entirely sure why we are not allowed to witness a DNR. It makes sense because we witness for everything else. That is just our hospital policy. Apparently it isn't like this everywhere....:wideyed:

The physician writes the order but we still need the paperwork on file.

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Specializes in Trauma Surgical ICU.

That is just crazy and plan stupid.. I can see needing two witnesses outside the hospital setting for a DNR or POA etc but in the hospital. Getting other visitors involved in matters not related to their own family is disturbing, a huge burden they should not have to bare. DNR in all the facilities I have worked is just that, an order. The family need not to sign anything, nor the nurses except to sign the order off like we would for a new medication or labs.

Have you read the policy yourself?? Reason I ask is because I hear a lot of things are "policy" but they are NOT, it just happened to be the way they did things..

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Specializes in Nephrology, Cardiology, ER, ICU.

Huge HIPAA violation and doubt this is the whole story. No institution could get away with this.

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Specializes in Trauma Surgical ICU.
Huge HIPAA violation and doubt this is the whole story. No institution could get away with this.

I was thinking the same thing.. Code status is PHI. This might be the way to get the "policy" changed.. HIPAA violations can cost the hospital large amounts of money. I would go to risk management if your normal chain of command is no help.

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Specializes in Acute Care, Rehab, Palliative.

There is something wrong with that situation.All you should need is the doctors order.

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Agree, this is strange.

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Specializes in Emergency, Telemetry, Transplant.

I am really confused by the situation (which is probably just my mind, but oh well...). Did the MD have the talk with the family well before the family decided to make the pt a DNR and now you were stuck in the position of trying to make them a DNR when there was no doctor present? Based on the the OP it sounds like the policy is that the pt/POA can make the DNR decision, tell a nurse who finds 2 random witnesses and that is all it takes. Am totally missing it. It just all seems weird to me....again, that might just be my misinterpreting it.

Also, as people have mentioned, this sounds like a HIPAA disaster! Pull a stranger into a room to witness a pt telling them they are a DNR?? Suppose you didn't realize it in advance, but suppose that witness has something to gain by knowing that the pt is going to die? The privacy issues there just blow my mind.

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It can take more than "just" a physician order. Some facilities want it signed by a second MD. At my last facility, getting a telephone DNR order required a witness, so we'd put the doc on speaker and two nurses would sign the telephone order. But there is absolutely no situation in which it is appropriate in a hospital to get a random visitor to sign something. This is just plain weird. I'd also double check this is really the policy and if it is, take it to risk management.

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