If you have a DNR/DNI....

[ChillyWilleys]

Unfortunately even with something like that these situations would probably still happen, the reason I was told at my hospital which sounds harsh but probably is quite honest is that, dead people don't sue. Its the family that is going to speak up and be crying at you, and its the family that is going to take legal action. That poor man on a vent clearly won't be heading to a lawyer, but his family may have. Granted with all the documentation they wouldn't have a case, but its a hassle that nobody wants to get into nor do they have the time to think it through while the man is crashing. It was very selfish of the family to do, but I can't honestly say with 100% assurance that I would have been strong enough to let him go either.

 

[Pea-n-Me]

I knew her wishes as did her children. She absolutely did not want to be put on any machines.

Her oncologist asked us at that time if grandma had a DNR. We had to say "yes" because it was her wish. Grandma was moved to CCU and was slowly improving until they put a purple bracelet on her left wrist. She asked what it was for and they told her it was "to let them know that if her heart stopped they weren't to restart it." That is when she took a turn for the worst and decided that she was going to die. She told me that evening that they said "my heart isn't strong enough to make it. I'm not gonna make it." The nurse told me she was very upset when he put the bracelet on her and explained it to her. He said if they had put it on her in the ER like they were supposed to instead of waiting 3 days that she wouldn't have even known it was there.

I do believe in upholding a loved ones wishes but I also think things need to be handled very delicately on the medical end in a case such as this. We did our part but what would have happened before the bracelet?

I'm sorry about your Grandma. It sounds from your post that your grandma had a desire not to be resusciated but that there were no actual legal directives made before she went into the hospital? (Which would explain why no bracelet could be applied in the ER).

What has to happen is that her attending physician has to have a discussion with her to explain her condition and review her wishes before actually ordering DNR/DNI. If she was awake and alert this would have occurred with her, and perhaps the family also, but ultimately if she is able to, then she will be the one to make the decision. She may not have understood exactly what this meant - there's so much going on it can get confusing - but if I were her nurse under these circumstances in putting the bracelet on I would have explained to her what it meant, including the fact that it didn't mean that we were not going to treat her or that we were giving up hope, just that if the worst happened we would let her go peacefully and not put her through the pain of resuscitation; and I would also call back the attending physician to have him or her review it again and offer assurances about it as well.

What most people don't realize is that the agency that accredits hospitals mandates that "code status" be addressed with every patient who comes to the hospital. Those that don't comply risk losing accreditation. So every patient who comes in is asked their desires, and we even have to offer them the paperwork to fill out directives if they don't already have them in place. However, with that said, for most people coming in to the hospital, it's not exactly an urgent issue unless someone is critically or terminally ill, when it becomes a little more pressing to know exactly what the patient desires.

Full resuscitation is not pretty. If someone is expected to die, it's a kindness to let them go without the suffering what a "code" entails (electric shocks with defibrillation, broken ribs with chest compressions, tubes down throats for ventilation, urinary catheters placed, big needles placed in the neck while bed tilted upside down for a central line, buck naked with a room full of people, etc). Obviously, this would be different for those who aren't expected to die and/or have a chance for full recovery.

 

[daisax]

I told her that she better tattoo it on her forehead because I would never give them the papers. Call me selfish but that's how I feel.

Please see Pea-N-Me's post above for a description of what happens in an actual code. It's not like on tv -- it gets gruesome and the repercussions can be horrible for someone who's already completely fragile.

Obviously in someone otherwise strong and healthy who's suffered a trauma, the negatives are outweighed by the positives. But in the very elderly or very sick, it often amounts to torture and a few extra remaining days of medical procedures and indignity.

 

[DVC-Don]

I personally know a fire chief in a small Massachusetts town who lost his job over a DNR situation. They responded to an EMS call where a family member demanded they treat and transport the fellow to the ER. One family member said there was a DNR but could not locate it and other family members, like I said, demanded action. He ordered the treatment and transport and the town and he was later sued. The town fired him and had their insurance company settle the matter. It gets confusing. This was back in the early 1990's.

 

[DawnCt1]

One year prior to my mother's death, I rushed her to the emergency room with septic shock. She was "terminally ill" at the time with metastatic breast cancer. Her initial symptoms were malaise and low grade fever. Once inside the ER she "crashed". We got her into a room and they initiated life saving procedures. Her consulting urologist pointed out to me that she was "terminally ill and this isn't a bad way to go". I pointed out to him that she was shopping with me last weekend and if he does his job, we will be in the mall next weekend". They brought her blood pressure back from "not palpable", and prior to transfer to ICU, the ICU doc came down to secure an "advanced directive" or DNR. She looked at him and said, "YOU KNOW, IF I WANTED TO DIE, I WOULD HAVE STAYED HOME!" This is one of my favorite stories about my mom. She had a great sense of humor when no one else was laughing and her spirit to continue gave us another year with her. No one ever knows when it's "time" sometimes until it is actually "time".

 

[Pea-n-Me]

She looked at him and said, "YOU KNOW, IF I WANTED TO DIE, I WOULD HAVE STAYED HOME!"

Too funny, good for her!

Obviously in someone otherwise strong and healthy who's suffered a trauma, the negatives are outweighed by the positives. But in the very elderly or very sick, it often amounts to torture and a few extra remaining days of medical procedures and indignity.

Well said.

 

[DisMN]

I think the situation is, if EMS is called, they have to initiate life saving measures. They cannot take the word of a family member that the person is a DNR. If the family knows that there is a valid DNR and allows the patient to die at home, then that is okay, but once they pick up the phone and dial 911, the full response can be expected. My mom passed away at home. She was DNR because her condition was hopeless. On the day that she was passing, the hospice RN stayed with us. I think in part to discourage me from calling 911 if I had a sudden change of heart. She told me that if I called 911, we would not be able to 'control' the situation. Perhaps the family in this situation saw him fall acutely ill and panicked, dialing 911.

We waited for my father-in-law to pass but were NEVER told who to call when he finally did. We called 911 of course which was totally NOT the thing to do..........but we've still never found out who we should have called.

So? Who do you call when someone dies? (I'm talking about an expected death, of course)


OP my heart goes out to you in situations like this. Tough tough choices and decisions for family and caregivers. A database would be a start.

 

[DawnCt1]

We waited for my father-in-law to pass but were NEVER told who to call when he finally did. We called 911 of course which was totally NOT the thing to do..........but we've still never found out who we should have called.

So? Who do you call when someone dies? (I'm talking about an expected death, of course)


OP my heart goes out to you in situations like this. Tough tough choices and decisions for family and caregivers. A database would be a start.

The hospice nurse called the funeral director.

 

[TeresaNJ]

Family has the last say. Even if the patient has a DNR order, even if it is done correctly, the family can rescind it. I see it happen all the time and it sickens me.

 

[chris1gill]

She looked at him and said, "YOU KNOW, IF I WANTED TO DIE, I WOULD HAVE STAYED HOME!"

That is one of the FUNNIEST lines I have ever read... I'm so glad you got the extra year with your Mom.... and I hope you made it to the mall soon after her hospital stay....

 

[chris1gill]

The hospice nurse called the funeral director.

Exactly,

MIL did not tell us that FIL had taken a five day turn for the worse mid-week when we were not back home in December, she decided to wait until Wednesday night to tell me she had to call paramedics FIVE times over 3 days to come pick FIL up off the floor, he kept slipping out of bed when he wanted to stand up. Well, they told MIL to take him to the doctor to find out what was wrong with him.... were they nuts? They should have told her to call hospice, I don't know why the doctor never mentioned it, but he was dying, but okay. I got on the phone right away, and got nursing staff in the house for Thursday, we arrived Friday, hospice started Saturday morning early, and FIL unexpectedly went a few days to a week earlier than expected at 2:20am on Monday morning, after DH & the kids went back to our new home. I called the hospice nurse who'd spent 5 hours with us that day, prior to the 10pm night nurse coming on, when FIL took a turn for the worse after DH had left. I think he was waiting to see DH one more time before he died & when DH left for the week, FIL whether consciously or unconsciously started the dying process the minute DH left. The hospice nurse when she had to come back did all the paperwork, the funeral director is a friend of ours, and he came at around 5:30.

Leading up to this, on the Wednesday prior we had our doctor fill out the Massachusetts form for EMT's in order to give them permission to not resuscitate. This was probably put in place due to the event described above where life saving measures weren't given for a DNR by the EMT's and the top guy lost his job.... I guess the reason for the form specifically for EMT's....

As an aside, hospice is amazing, and I wish to God we'd known about it sooner, and that we could have gotten services... it would have made the last 3 weeks so much easier.

 

[DawnCt1]

That is one of the FUNNIEST lines I have ever read... I'm so glad you got the extra year with your Mom.... and I hope you made it to the mall soon after her hospital stay....

It was amazing. If you can picture a major resusitation effort, everything short of CPR because she still had a heart rate and respirations, the staff trying to get me to wait in the hall, etc. The tension and the anxiety, and to have her "come to" and say something like that. She was sick for about 4 weeks after that but did recover enough to go shopping, live on her own again for a while, etc.

 

[chris1gill]

It was amazing. If you can picture a major resusitation effort, everything short of CPR because she still had a heart rate and respirations, the staff trying to get me to wait in the hall, etc. The tension and the anxiety, and to have her "come to" and say something like that. She was sick for about 4 weeks after that but did recover enough to go shopping, live on her own again for a while, etc.

I can TOTALLY see it... FIL came to that Friday night before he died just 52 hours later... He had alzheimer's, it was severe, but he came through, and he was aware DH was there and DH slept in the room with him, but by Saturday he didn't know who DH was, but by Sunday he was asking where DH was after DH had left.... he was in and out that weekend (most out than in, but still) I totally get that feeling that comes from when you're watching something like this, the person just comes up with something that makes you go WOW.... FIL did the same thing.... as soon as he saw DH Friday night, he knew him, told him he trusted him, he was his guy, while MIL & I just stood there with our mouths open... that was as lucid as that man has been in probably more than a year!

 

[Disney Doll]

DNR situations can be so terribly difficult.

The bottom line is that it really doesn't matter how much paperwork you have in place...if your family decides not to honor the DNR, we are resuscitating you.

As a PP said, dead people don't sue, but their families do.

I have made my wishes perfectly clear...even written them down in my own handwriting...but I'd still have to trust in the fact that my DH would love me enough to let me go. And if he doesn't, then I would be made to suffer the indignities of being resuscitated against my will.

And yes, I would consider him selfish if he did that to me.

 

[BMNABrinx]

Pea-n-me,

Thanks for your response to our situation. I should have clarified that in the ER my grandmother was not able to speak for herself but the family did tell the doctor's of her DNR wish. In fact there was a living will on file with the hospital. For some reason they didn't put the bracelet on her.
She was a wonderful woman and until that very day she was able to do nearly everything for herself. She told me everytime we went to the doctor, which was very frequently the last month and a half of her life, that she did not want any measures to be taken to prolong her life. She wanted to go "home" and if God called just let her go. Despite the pain of living without her how could we not respect her last wish?
Each and every nurse that cared for my grandmother was an angel. Even though they knew that she was dying they were so attentive and treated her with such love and kindness. They spoke to her first then if she didn't answer they asked a family member the question they had just asked her.

 

[Pea-n-Me]

Thanks for responding. I'm glad your Grandma received good care. I guess I would have expected that when she did wake up (later, in the CCU), that her attending doc would have had conversations with her confirming that she still wished to be a DNR/DNI, because as I said earlier, code status has to be addressed with each and every hospital admission, even when paperwork is on file. People can change their code status if they want to, sometimes the situation warrants it.

 

[LaraK]

A lot depends on what state you're in, so a federal registry would not be effective as DNR/Advance Directive laws vary so much.

In my state, you have to have a special DNR for ambulance transportation to avoid being coded in transit by EMS.

I have also been in situations where families have recinded Advance Directives their loved one made. It gets really really sticky...but if they say the patient changed their mind, you recind it.

Also, you have to validate the accuracy of an Advance Directive with every new patient encounter...that's going to take at least some amount of time, even if you have an old AD on file.

 

[mudnuri]

Okay a few answers.

1st, this patient is normally treated at a neighboring hospital. it just happens that our hospital is closer to his house- (by a few blocks).... he was in severe respiratory and cardiac distress, and therefore went to the closest trauma center...that was us

2nd- EMT's in both NH and VT are NOT to override a standing binding legal DNR document.

Scenario is- you ASK does the patient have a DNR - I'm an EMT as well so I know the drill. Anyone present can answer- if they HAVE the paper, we do not 'save' them. If they do NOT have the paper, yup we tube them...it's simple that way...

however a database would solve this- because dispatch could access it..

this patient came in on CPAP, so the EMT's did not perform CPR...they assisted in non-invasive ventilatory support. They did perform life saving measures- because the deal is that now we look for cpap or i/epap to work before we actually intubate (if the time allows)

The patients family notifiied the ER doc 1.5 hours into the treatment, when he was going over medications and so forth with the wife and son. At that point, they said it. Our ER doc called the neighboring hospital and got a copy of it fax'd over.

Yes, at our hospital, until a DNR is written as an ORDER every single time the patient comes in, they are not DNR. Even if I know patient- and know they have a legal standing DNR, until the treating doc writes it as an order, I tube them.

It still sucks, I'm guessing he is still vented and i will see him tomorrow I'm sure when I'm doing vent checks etc... I just hope I'm not the one to extubate!

Now that he is intubated, we can NOT extubate him because of a DNR order, he would have to have no brain activity, etc.. basically be on full life support with no chance of recovery and the family would have to make that decission.....extubating end of life just plain sucks!

Brandy

 

[DawnCt1]

Okay a few answers.


Now that he is intubated, we can NOT extubate him because of a DNR order, he would have to have no brain activity, etc.. basically be on full life support with no chance of recovery and the family would have to make that decission.....extubating end of life just plain sucks!

Brandy

Not necessarily. DH's cousin had an acute illness at the age of 59 that resulted in him being intubated. While hospitalized they discovered that he had a huge metastatic ca. on his adrenal glands that had spread through his belly and invaded his spinal cord. It was inoperable. They attempted to wean him from the vent unsuccessfully. They removed a lot of the sedation during the process and explained his very dire situation to him. He made the decision with his family to be extubated. We went to visit him prior to the extubation and stayed with the family for a while afterward. They sedated him so he would not be uncomfortable and he died within 6 hours. Decisions are made to extubate patients every day. One doesn't need to be brain dead to make that decision.

 

[Pea-n-Me]

I'm sure this thread will be an eye opener for many.

I think the system we have in MA is a good one. The MA Health Care Proxy form allows you to legally delegate someone to make health care decisions for you in the event (and only in the event) that you can't. If you pick someone who you trust will abide by your wishes, then you don't need to worry that family members will change things at the last minute. If there are family issues then sometimes people appoint a friend or clergymember instead. I don't recall ever seeing anyone go against a HCP; in fact, not only would it be illegal, but unethical. Dead people may not sue, but those of us caring for patients have to sleep at night.