DNR INTERACTIVE CASE STUDY
Complete the interactive case study. Associate what you have studied in your weekly materials and what is presented in this case study
After you complete the case study, use the journal tool in blackboard to reflect upon what you have learned from the case study and related learning materials this week. Compare this case study to your nursing practice and give a similar example from your nursing experience in which you might have run into an ethical situation.
It’s been a long day: You have a patient who is actively dying after a sudden CVA (Cerebral vascular accident). The family has been camped out all day at your workstation.
CODE BLUE, CODE BLUE: ROOM 142 BED 1
The patient is unresponsive, and the CNA (Certified nurse aid) is performing CPR.
You are the nurse scream at the CNA; Do not Resuscitate! He has a DNR!
I have the power of Attorney! (POA). He has a living will that states tall heroic measures must be taken!
The family seem to have conflicting information.
What should you as the nurse do to calm the situation down?
Escort the family out while calming them down. You need to concentrate on the patient. You have something in your pocket. You take it out: It is a DNR card for the patient with information on it such as
Name: John Williamson, Address 123 Main St. Phoenix Arizona.
Keeping these cards in your pocket can be critical. As in this instance, it helped to confirm that the patient was indeed a DNR Upon admission to the floor.
You as the nurse scream; Stop CPR Immediately, the CNA has stopped CPR. You need to check the patients’ vital signs. The patient ends up having no palpable pulses and there are no signs of life.
The nurse tells the CODE BLUE TEAM That the patient is a DNR status, and they should leave
Family member screams at nurse: /code blue team. Get back in there! You need to resuscitate him! The son is upset, But the patient had a DNR upon admittance. As we continue, think about the following questions.
Did the nurse have a crucial role to play in this situation? If so, what was it? What responsibility? If any, does the family have in a situation like this, what responsibility, if any did the patient have in this situation?
The doctor asks the nurse; please tell me the sequence of events. Nurse’s response: The patient remained on bed rest after his IVC Filter surgery that concluded at 16:30, he had been stable, He requested to get up with CNA assistance to go to the bathroom at 18:15, and I provided the ok for him to walk to the restroom with the assistance of the CAN after one incision assessment. The CAN reported that, while getting him out of bed, it was discovered that oxygen tubing was short. She left to get longer tubing for the patient’s oxygen. Leaving the patient under the supervision of his daughter. When the CAN got back. She that the patient had taken off the oxygen and left it on the bed as he tried to get up on his own despite the pleading of his daughter not to. She witnessed the collapse and yelled for help as the CNA was returning to the room. The CAN, unaware of the DNR status, began CPR and called CODE BLUE.
The doctor is satisfied with the report. He asks to speak to the family. Can you all please come with me so we can talk?
Family member is furious and says: I’m going to sue this hospital.
Nurse: You overhear the outburst; Your intuition tells you that you are going to court.
ADVANCE DIRECTIVES: Is a term used to encompass documents such as a living will, durable power of attorney, and durable power of attorney in health care (DPAHC). A living will is simply a statement that the patient makes in writing describing his/her wishes pertaining to how, or where he/she wishes 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 a legal representative in all non-health care legal matters involving a patient (Like an elderly person). A DURABLE POWER OF ATTORNEY FOR HEALTH CARE (DPAHC) is a document through which a patient makes known his/her wishes about the treatments he/she wishes 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 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.
DNR: 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 health care providers to honor their preferences.
DNR; Clinical scenarios like this a tenuous at best, and more so if a family is in disagreement with 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 health care providers withheld care, was an influence in their decision to file a lawsuit.
There are a lot of nuances to what 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 power of attorney can override the wishes of a patient, and lack of communication between both patient and family.
Perhaps the son could have double checked the code status with the Physicians and verified that the advance 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 not better advocates for health care consumers than themselves (The patients), Family members, or trusted friends who hold the durable power of attorney for health care (DPAHC). That said, we should always ask ourselves: does a family member or one who hold 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 give 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 care 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 (ie,CHF).
While nurses seem to approve of and support discussion 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 is our responsibility as nurses to one very important to teach patients and their family members one very important thing; With every hospitalization or change in health status (Advance 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 healthy death. “It would serve our families well (prevent costly lawsuits) if we started the conversation and engaged in thorough teaching about advance care planning.
DNR INTERACTIVE CASE STUDY