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Clinical Nursing Case Studies
Nurses Followed Dr.'s DNR Order On Patient, Confusion about Advanced Directives
D Myrna Wheelock, ET AL. v. Jesse Thomas Doers, M.D., 2010, E2009-01968-COA-R3-CV
by Amanda Trujillo, MSN, RN

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Summary: A nurse advised the CNA to stop CPR on a patient who had a DNR order in place, the family objected and filed a malpractice suit against the hospital, physician, and nurse involved in the case.

It's 1830 and there's only half an hour left until you are done with what has been a rather horrific day. Your caseload has been taxing, to say the least: one 96 year old Alzheimer's patient you've been assessing and documenting on every two hours, two fresh PACU patients, and one patient actively dying after a sudden CVA whose family members have taken turns camping out where your work computer is located. Needless to say, you've got nothing left to give. As you sit down to enjoy the iced coffee a girlfriend brought you an hour ago you lean back and close your eyes, drawing in a deep breath. You did it. Everyone's still alive. You're a rock star. Your body begins to let go of all that tense energy….

Just then, a code is called overhead. It takes a moment to register that it's your room everyone is running to. Fight or flight makes a quick comeback from the locker room (where started a nice hot shower) and you sprint down the hall, pushing your way through a cluster of your colleagues standing in the doorway. Your patient is unresponsive on the floor and the CNA is performing CPR. The family members are frantic, one of the three daughters is yelling that the patient is a DNR, but the son is growling back that he is the power of attorney and the living will the patient filled out 2 years ago indicates that he wishes to have all heroic measures taken. You give a knowing look and a nod to your best buddy who is also the charge nurse-- she knows exactly what you want done—and she grabs another nurse to help her escort the family out of the room. Reaching into your pocket you take out the notecard you have for this patient and sure enough it confirms that the patient is indeed a DNR upon admission to the floor. You advise the CNA to stop CPR immediately. You assess that the patient has no palpable pulses and there are no signs of life. The CODE team arrives and you tell them that your patient is a DNR status so they turn around and begin to leave the unit. The son's voice can be heard yelling in the hall commanding the CODE team to return. One of the daughters has now come back and sits quietly in the corner of the room appearing stunned.

Shortly after you and your lift team have gotten the patient into the bed the doctor arrives. You brief him on the sequence of events as reported to you by the CNA: The patient remained on bed rest after his IVC filter placement surgery that concluded at 1630. He had been stable. He requested to get up and go to the bathroom at 1815 (the patient was to be on bed rest for two hours) and you provided the OK for him to walk to the restroom with the assistance of the CNA after one last incision assessment. The CNA reports that while getting him out of bed it was discovered that the oxygen tubing was too short so he ran to get longer tubing for the patient's oxygen to remain on while in the restroom leaving the patient under the supervision of his daughter. When the CNA got back he found the patient had taken the oxygen off and left it on the bed as he tried to get up on his own despite the pleading of his daughter (she filled in the gaps for you). She witnessed the collapse and yelled for help as the CNA was returning to the room. The CNA, unaware of the code status, began CPR and called a code blue.

The doctor, scratching his head, appears satisfied with your report and turns to the patient's daughter, gently requesting her to come with him so he can talk to the whole family together. She nods, and allows him to guide her out of the room. Your charge nurse brings in a body bag and offers to help with postmortem care as it is now shift change and your other coworkers are in report. A sudden loud, angry outburst from the son in the hallway makes you both look up at each other and its then you know in your “nurse gut” that you're going to court.

The Real Thing

In 2010 a case similar to the one above played out in Knoxville, Tennessee. An elderly gentleman was transported from a nursing home to a hospital emergency department with a chief complaint of shortness of breath. Upon further testing it was discovered the patient was suffering from massive pulmonary emboli. The physician explained to the patient that the prognosis was quite poor, but offered to place an IVC filter anyway. The patient agreed to the surgical procedure and made it clear to the physician that he did not want any heroic measures taken if he went into cardiopulmonary arrest. The doctor documented thoroughly—he mentioned the alert and animated state of the patient, quoting the patient directly with regards to his wishes to be a Do Not Resuscitate status while also noting the man's poor prognosis.

After undergoing the IVC filter placement the patient experienced an uneventful recovery period (bed rest) and was allowed to ambulate to the restroom with the assistance of a CNA by approval of the RN. Upon discovering that the patient's oxygen tubing was too short the CNA ran to get a longer length to walk with. As the CNA was returning he heard family members in the hall calling for help. The patient was found on the floor of his room unresponsive. The CNA called a code and immediately began CPR. When the RN arrived she told the CNA to halt CPR because the physician had entered a DNR status for the patient. The family members in the room, horrified, demanded that the patient receive full intervention. The RN explained that the patient had specified to the doctor that he wanted no heroic measures taken. The son countered that his father should receive life saving measures because he was the power of attorney for his father and possessed the advanced directives that had been filled out by him for some time prior to this hospitalization. Again, the RN explained that the patient's current decision and the order entered by the doctor were things she could not go against.

Questions for consideration:

1. Did the nurse have a crucial role to play in this situation? If so, what was it?
2. What responsibility, if any, does the family have in a situation like this?
3. What responsibility, if any, did the patient have in this situation?
4. What, if anything, could have been done to prevent litigation here?
5. Does a Power of Attorney have the right to “override” a healthcare decision made by a patient and discussed with a doctor just prior to a critical event such as this one?
6. Which healthcare decision by the patient takes precedence in a situation like this one? (One made just hours before a critical event and discussed with a doctor, or an advanced directive signed by the patient two years ago?)
7. Should a nurse inform family members during a hospitalization of the patient's decision for a DNR or Full Code status? Why or why not?

Outcome On July 6, 2010 in the case of Wheelock versus Doers (MD) the court decided in favor of the physician and the hospital. The family members who had filed suit failed to provide expert witness to demonstrate evidence of malpractice as defined in the Tennessee Medical Malpractice Act (Tenn. Code Ann. 29-26-115 et seq). They also failed to provide evidence that the lack of CPR and emergency measures contributed to their loved one's death. While the nurse testified the patient might have survived with emergency measures she was not qualified to give a medical opinion. The doctor's testimony, coupled with thorough documentation related to discussions with the patient, were what contributed to a decision in their favor.

Discussion

Advanced Directive is a term used to encompass documents such as a Living Will, Durable Power of Attorney, and Durable Power of Attorney in Healthcare (DPAHC). A Living Will is simply a statement the patient makes in writing that describes their wishes pertaining to how or where they wish to die, and it becomes active when a person has been deemed incapacitated (vegetative state) or terminally ill. A Durable Power of Attorney is a legal document that allows a trusted individual (friend or family member) to be the legal representative in all non- healthcare legal matters involving a patient (like an elderly person). A Durable Power of Attorney for Healthcare (DPAHC) is a document through which a patient makes known his/her wishes about the treatments they wish to have (or not to have) throughout the course of an acute illness or in the dying process. Had the son in this particular case, kept an ongoing and open discussion with his father about any changes he wanted to make to the DPAHC prior to the emergent hospitalization, the son may (or may not) have had more decision making capacity. Unfortunately, that wasn't the case and thus there was an unfortunate disconnect between the two key parties involved in the DPAHC—the appointed decision maker and the patient. This is not an unusual occurrence. A recent study expands on this by stating “When discussions about end of life preferences do take place, they frequently lack the clarity and detail needed by significant others and healthcare providers to honor their preferences.” (Bergman-Evans, 2008)

Clinical scenarios like this are tenuous at best, and more so if a family is in disagreement with each other or their loved one at the time of an arrest or when actively dying. One has to wonder if the horror the family experienced as they witnessed their father's life come to an abrupt end while healthcare providers withheld care was an influence in their decision to file a lawsuit. There are a lot of nuances to what we do that are not well understood by laypersons. Three pieces of information concern me in this case: The lack of communication between the father and son with regard to updating the patient's preferences, the misunderstanding the son had that a power of attorney can override the wishes of a patient, and the lack of communication between both patient and family. Perhaps the son could have double checked the code status with the physician and verified the advanced directives were in the chart or updated with the patient prior to surgery? Maybe a conversation between father and son prior to surgery could have closed the circle of communication.

The fact is this: there are no better advocates for healthcare consumers than themselves, family members, or trusted friends who hold the Durable Power of Attorney for Health Care (DPAHC). That being said, we should always ask ourselves: does a family member or power of attorney know what effective advocacy means? Part of advocacy is knowing what questions to ask, what information to provide and verify in the hospital, and always knowing at any given moment the exact wishes of a loved one so there are no surprises or unnecessary (and unhealthy) turmoil surrounding a patient and family during a health crisis. Advance Care Planning would have played a critical role here and this case illustrates why. With every hospitalization or change in health status there should be a family talk taking place so that everyone is in line with what the patient wants treatment wise under various circumstances or stages of illness (i.e.: CHF).

Conclusion

Patients change their minds. Hell, we all change our minds. But Advance Care Planning can prevent people from receiving unwanted treatment that could be harmful and painful or care that prolongs life when it's the last thing a person wants to do. Ideally, consistent Advance Care Planning long before the hospitalization would have made for a much smoother transition for this family and perhaps could have prevented a costly, time consuming, and painful lawsuit for everyone involved.

While nurses seem to approve of and support discussions related to end of life preferences and Advance Care Planning they lack sufficient knowledge to feel comfortable initiating or engaging in crucial conversations: “Studies have found that nurses identify the benefits of advance directives and have positive attitudes but lack knowledge and confidence to effectively discuss end of life issues with patients and families. The literature related to nurses' attitudes about advance directives points to an unmet need for increased knowledge and confidence to address barriers and ethical dilemmas in end of life care.” (Putman-Casdorph, 2009) It's our responsibility as nurses to teach patients and their family members one very important thing: With every hospitalization or change in health status (advancing disease) “the talk” has to happen. Questions must be asked. Advance Care Planning doesn't stop once an Advance Directive is signed. The concept is a “living” thing. The patient's voice must remain front and center during each discussion and each stage of illness up to death. Believe it or not, there is “wellness” in “illness” and such thing as a “healthy death.” It would serve our families well (and prevent costly lawsuits) if we started the conversation, and engaged in thorough teaching, about Advance Care Planning.

Works Cited D Myrna Wheelock, ET AL. v. Jesse Thomas Doers, M.D., ET AL, E2009-01968-COA-R3-CV (Court of Appeals of Tennessee, at Knoxville July 6, 2010). Retrieved 7 29, 2012

Bergman-Evans, B. K. (2008, September 23). Uncovering Beliefs and Barriers: Staff Attitudes Related to Advance Directives. American Journal of Hospice and Palliative Medicine, 25(5), 347-353. doi:10.1177/1049909108320883

Ebersole, P. H. (2004). Toward Healthy Aging. St. Louis, MO: Mosby.

Putman-Casdorph, H. D. (2009). Advance Directives: Evaluation of Nurses' Knowledge, Attitude, Confidence, and Experience. Journal of Nursing Care Quality, 24(3), 250-256.

Report, Nursing Law's. (2010, 7 6). Nurses followed Dr.'s DNR order on patient. Retrieved 7 29, 2012, from The Free Library by Farlex: http://www.thefreelibrary.com/Nurses+followed+Dr.'s+DNR+order+on+patient.-a0239659287

Key Terms: medical malpractice, standard of care, patient, nurse, summary judgment, cause of action, medical treatment, causation, care provider

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This page was created on Wednesday, March 23, 2011

Last updated by Andrew Lopez, RN on March 23, 2017


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