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?

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 friend brought you an hour ago you lean back and close your eyes, drawing in a deep breath. You did it. Everyone is 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 is your room everyone is running to. Fight or flight makes a quick comeback from the locker room 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 like 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

DNR 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. 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? 8. What nursing principles apply to this nursing scenario if any? 9. What Standard of Care and Scope of Practice rules apply here, if any?

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