[SOLVED] DNR Interactive Case Study
DNR Interactive Case Study
It’s been a long day. You have a patient who is actively dying after a sudden CVA. The family has been
camped out all day at your workstation. Code blue, code blue, room 1421 bed 1, code blue, room 142,
bed 1. The patient is unresponsive and the CNA is performing CPR. Do not resuscitate! He has a DNR. I
have the power of attorney; he has a living will that states all heroic measures must be taken. The family
seems to have conflicting information. What should you do first to calm the situation down?
Think about the answers below. When you’re ready, click continue to see what the best option is.
• Tell the family they are out of line and need to leave the room immediately.
• Engage in conversation immediately with the family right there in the room.
• Escort the family out while calming them down so you can focus on the patient.
Escort the family out while calming them down. you need to concentrate on the patient. You have
something in your pocket..
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.
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.
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?
Please tell me the sequence of events:
• The patient remained on bed rest after his IVC filter placement surgery that concluded at 16:30.
He had been stable. He requested to get up and go to the bathroom at 18:15 and I 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. She left to get longer tubing for the patient’s oxygen 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 not to. She witnessed the collapse and yelled for help as the CNA was returning
to the room. The CNA unaware of the DNR status began CPR and called a code blue.
The doctors satisfied with the report. He asked to speak with the family. Can you all please come with
me so we can talk.
I am going to sue this hospital! You overhear the outburst. Your intuition tells you, you are going to
court. Advanced directives is a term used to encompass documents such as a living will, durable power
of attorney, and durable power of attorney and healthcare (DPAHC). A living will is simply a statement
that the patient makes in writing describing his or her wishes pertaining to how or where he or 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 the 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 health care (DPAHC) is a document through which a
patient makes known his or her wishes about the treatments he or 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 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.”
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 that 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 we do that are not well understood by laypersons. Three pieces of
information concerns 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 physicians and verified that 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.
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