Ethical question: to tube or not to tube?

[Doczilla]

My gut told me there was no foul play, and I thought it unlikely that both the husband and her father were conspiring to off her, although the husband was clearly driving the bus when it came to her care. There was no durable POA; we were just going by the usual OH rules regarding who makes those decisions, i.e., spouse, then parents, then grown children, then siblings, etc. Ethics committee is a good thought, but I'm not sure how we make that happen at 11pm on a weekend.

Ohio currently has two levels of DNR. A DNR-Comfort Care Arrest (DNR-CCA) simply states that no resuscitation will be undertaken in the case of a cardiac arrest. It is frequently interpreted to allow everything else, though we may modify treatment based on discussion with family. A DNR-Comfort Care (DNR-CC) means that no aggressive lifesaving measures will be taken. This is usually taken to exclude intubation, pressors, central lines, defibrillation, but not necessarily IV hydration, artificial nutrition, or antibiotics. There is legislation afoot in Ohio for the MOLST (Medical Orders for Life Sustaining Treatment), but at present the only way to express your wishes regarding specific treatments is in a written advance directive. As you can see, even here, there is room for debate, as some will say that brief life saving interventions would be permissible if the disease process is thought to be easily reversible.

Most patients I encounter do not have clear advance directives on what care they would or would not want, which complicates things for those of us in critical care and emergency environments. We often rely on family members to tell us what they know of their loved one to help us guide what we do. If they have no useful information, then we treat under the doctrine that most people would want to survive under any circumstances. Most of the time EMS is, frankly, not permitted to think beyond the written page. Only honoring a recent, signed, very explicit DNR order is perhaps medicolegally the safest way to go. This also fails to address the majority of futile resuscitation that we will perform. Of course, if the patient never said anything, we'll never know that they wouldn't want to suffer a lingering convalescence. Making this call on limited information, from sources other than the patient, is tough.

There is that critical time, the immediate resuscitation, that makes all the difference. If you can get someone through that initial issue in the ER, it is very likely the patient will survive. It could be that come patients see that respiratory arrest as an easy way out, and in fact, they are often correct, since the one intervention, intubation, at the critical time, is enough to get them over the hump, to a prolonged convalescence, which is what the patient may want to avoid if they have expressed their wishes not to be intubated. Does this change what we do if the causative issue is one that is potentially easily correctable, or iatrogenic, or self inflicted?

In the end, it was all academic. She maintained her own airway and did not require intubation in the ER. The patient was not terribly well educated on her insulin pump, and was also on a long-acting insulin, so it was thought that this, combined with a UTI, caused the hypoglycemia. She was admitted by PCC to the ICU. He made her a full code, and his documentation stated that he "was not satisfied with the documentation of her wishes regarding code status". The husband was apparently pretty unhappy about it, according to the chart. The patient fully recovered, and met with Integrative Care Management. In a well-documented conversation, the patient said she would not want to ever be intubated under any circumstances, and it appears the husband was correct. A DNR-CC form was executed, and the patient discharged home.

I bring this up because of the difficult position I was in, not just with the patient and family but with staff. The nurses taking care of her were very experienced and pretty headstrong, and they clearly would have put up a fight if something happened and intubation was medically indicated and I refused to do it. I'm not sure how that would have played out, but it likely would have involved the resource nurse, the Administrative Officer, another physician from the ER, and hard feelings all around. It would have been fairly ugly. We like to think that we run the place, but when the nurses feel an ethical obligation to do something, they can, and will, stand up to us, and refuse to execute orders they feel are not in the patient's best interest.

'zilla

[RichL025]

Originally Posted by swatsurgeon

...

There is never an excuse for a health care provider to not know the status (DNR, DNI) of a patient. ....

ss

With all due respect, this is a little strong. Yes, providers should make every effort to clarify the status of a patient prior to intiatiing resuscitation, but occasionally "real life" interferes with "noble principles". The ED or trauma bay can be a very hectic place, and providers have to use good faith efforts - and I have always been taught that the law recognizes this.

Now, the nurses in the example _knew_ the DNR status, they just chose to disagree with it. THAT I will concede, there is never an excuse for.

I wish I could remember the details of the incident, but I once had a POLST (advanced directive) presented to me _after_ we had initiated agressive resuscitation. We had, by that time, regained a perfusing rhythym but, after consultation with the family (who were very understanding as I recall) withdrew medical support and extubated, the patient died shortly afterwards.

I don't remember the specifics of why we didn't know about the POLST, but I seem to remember that it wasn't in the patient's medical records, and a family member brought it by the ICU and explained things to the nurses....

I acted in good faith though, and was not overly bothered by the episode.

[Doczilla]

Originally Posted by RichL025

Now, the nurses in the example _knew_ the DNR status, they just chose to disagree with it. THAT I will concede, there is never an excuse for.

They knew the DNR status based on the paperwork provided, but disagreed with respect to other aggressive life-saving measures. In Ohio, other specific measures are not listed in the DNR, particularly the DNR-CCA.

'zilla

[Retiredfire]

They love their BiPaP here in South Florida. People with valid DNR orders in respiratory failure are frequently ordered on BiPaP. It can not a ventilator, and doesn't require intubation. I think it is ethically wrong and nothing more than an attempt at an end-run on the patients wishes. People deserve the right to die on their terms. To all those that feel an need to save something, i suggest: http://www.savethetatas.com/

[swatsurgeon]

Originally Posted by Retiredfire

They love their BiPaP here in South Florida. People with valid DNR orders in respiratory failure are frequently ordered on BiPaP. It can not a ventilator, and doesn't require intubation. I think it is ethically wrong and nothing more than an attempt at an end-run on the patients wishes. People deserve the right to die on their terms. To all those that feel an need to save something, i suggest: http://www.savethetatas.com/

Being that it is non-invasive, some docs feel that it is a bridge to allowing the patient to hopefully get more time to be with their families, allowing us to intervene "non-invasively", and following a patient's wishes of no intubation, etc.
It respects the patient's wishes while also giving them a chance at prolonged survival ...if this is within their wishes. It should not be offered if they do not want it, but if they do agree, it can be a means to more time with their family.
The two parts of this are the desire on the part of the medical team to promote beneficience and non-malfesience while maintaining the patient/physician trust in the decisions made by the patient (either written or discussed) with our desire to help our patients. Most people on the 'outside' don't understand the dynamics involved when I have spoken to the patient and or family and are simply following their wishes....it confuses some of the team members because they are not involved with the day to day happenings of the patient and don't read the progress notes that we leave on the discussions with the patient. We are judged by everyone who does not know the details of the discussions or the caring that goes into the relationship between doc and family during end of life care..

Don't judge until you are on the inside.....

ss

[Retiredfire]

Sometimes it seems that the patients wished are forsaken for the families inability or unwillingness to let go. I am curious as to the right of a family member to modify an advanced directive.make sure you appoint someone you can trust to follow your wishes, and don't wait until you are in the hospital.

[Saturation]

Originally Posted by Retiredfire

I am curious as to the right of a family member to modify an advanced directive.

Years ago I had an ICU doc state- it's not the patient I save that is going to sue me but the family when he dies. Of course that has changed (see earlier posts) and I have seen that attitude shift as well. Generally I have seen families greatly relieved that there is some sort of direction (and by extension less responsibility and less guilt). My experience is that families don't try to change the Advance Directives until the doctors are saying the care is futile but the person wanted everything done.

I don't run into as many bipap machines as you do but many families need that time to process the reality of what is happening. Inasmuch as it's non-invasive it is typically accepted in end of life care.

As you stated being in South Florida, you are probably familiar with many of our residents not having local family and many times limited interaction with their family out of the area. If the family is interested enough to actually make the trip, that family member is seeing the patient for the first time in years??? and then feeling like they are 'pulling the plug'.

Don't worry, some don't even come- they just handle it all through the phone and fax machine.

[Retiredfire]

I can remember as a newly minted medic being called to the unresponsive patient. upon arrival I discovered a 70 something male with a history of metastatic lung cancer. His RR was like 4 and pupils pinpoint. A concerned family member states that she thinks he OD'ed on his Oromorph. I treated accordingly to the standard of care and the patient lived to suffer another day. I wish i didn't have render treatment, but he was immediately faced by a reversible condition that could be corrected without violating his Advanced Directives. (literal interpretation as Intent is reserved for Judges and Scholars). Was my decision to give enough Narcan to correct his hypoventilation morally and ethically correct? Anyways I'm sure the family member that called 911 would of sued if i didn't.

When I was Deputy Sheriff we were always called along with the FD to a scene to make sure it wasn't going to be a crime scene first.

One night my partner and I received a call to go to such-and-such a place along with the paramedics because of a person supposedly dying. We get their first and see him sitting at the dinner table. His wife is on the couch.

We ask him what is going with him and he says a bad heart. He collapses right after that. We just started to get him in position for CPR when the medics arrive. They come on in and take up where we had just started. One medic and I are asking her some questions about her husband laying there. Mine were short and sweet because it all smells fishy to me on why she is not emotional about what is happening all around her. Paramedics have now been working on this guy for over 5 minutes now and has coded twice and after each defib it returns back to normal for a few minutes then goes back again into V-Phib. I offer the medics some of my help and they tell me if i can get on the horn to the hospital then give it to one of them that would be great. I did. I go back to the wife to ask her more questions and now she will not tell me anything, period. In fact she stopped talking to the medics too. Now a few more minutes goes by and they are talking to the ER doctor.

The wife now gets up and walks into their bedroom saying nothing. This isn't looking good so I follow her. Once inside the bedroom she is motioning me to get out. I motion back telling her I am not leaving, and that I ask her out loud wha is she going to be doing here in their bedroom. She pulls a piece of paper out of a drawer next to the bed and hands it to me.

I look at it and immediately I know what I have here in my hands. It is on a white prescription note pad in big letters "DNR" and then it just goes on further to explain what DNR stands for and nothing else but the patients name. Nothing else.

I hand it to the medic who is wrighting down on what meds to shoot and other things such as his vitals. He then looks up at me and notices the paper I have in my hand and say what you got there Mark. I hand it to him and he cannot believe it and talks over the doctor and tells him we now have a DNR. You can hear the doc on the other line saying some 4 letter words and is really ticked off. His answer to the DNR is "F___k It, bring him in anyways!".

He dies that morning around 0830 give or take a few minutes.

Any Legal complications here?

[Red Flag 1]

Originally Posted by MAB32

When I was Deputy Sheriff we were always called along with the FD to a scene to make sure it wasn't going to be a crime scene first.

One night my partner and I received a call to go to such-and-such a place along with the paramedics because of a person supposedly dying. We get their first and see him sitting at the dinner table. His wife is on the couch.

We ask him what is going with him and he says a bad heart. He collapses right after that. We just started to get him in position for CPR when the medics arrive. They come on in and take up where we had just started. One medic and I are asking her some questions about her husband laying there. Mine were short and sweet because it all smells fishy to me on why she is not emotional about what is happening all around her. Paramedics have now been working on this guy for over 5 minutes now and has coded twice and after each defib it returns back to normal for a few minutes then goes back again into V-Phib. I offer the medics some of my help and they tell me if i can get on the horn to the hospital then give it to one of them that would be great. I did. I go back to the wife to ask her more questions and now she will not tell me anything, period. In fact she stopped talking to the medics too. Now a few more minutes goes by and they are talking to the ER doctor.

The wife now gets up and walks into their bedroom saying nothing. This isn't looking good so I follow her. Once inside the bedroom she is motioning me to get out. I motion back telling her I am not leaving, and that I ask her out loud wha is she going to be doing here in their bedroom. She pulls a piece of paper out of a drawer next to the bed and hands it to me.

I look at it and immediately I know what I have here in my hands. It is on a white prescription note pad in big letters "DNR" and then it just goes on further to explain what DNR stands for and nothing else but the patients name. Nothing else.

I hand it to the medic who is wrighting down on what meds to shoot and other things such as his vitals. He then looks up at me and notices the paper I have in my hand and say what you got there Mark. I hand it to him and he cannot believe it and talks over the doctor and tells him we now have a DNR. You can hear the doc on the other line saying some 4 letter words and is really ticked off. His answer to the DNR is "F___k It, bring him in anyways!".

He dies that morning around 0830 give or take a few minutes.

Any Legal complications here?

Lot of dynamics going on there Mark! Trip to the ER was probably a good idea. The doc on the phone had the ball, and you did what he said.

RF 1

[Saturation]

Originally Posted by MAB32

.... It is on a white prescription note pad in big letters "DNR" and then it just goes on further to explain what DNR stands for and nothing else but the patients name. Nothing else.

Any Legal complications here?

Based on what you describe on the paper, it was an improperly executed document. One could argue the intention was present but that's not something you can figure out in this context.
In my mind the intention was not strong enough---- meaning a Dr's signature on such prescription note and the individuals' signature would have given me more pause.

FWIW- In FL- if your DNR paper is completely signed, dated, MD license #, etc and on white paper- INVALID. On yellow paper (any shade mind you)- it's good to go.

Thanks guys. She did however sue all the way to the top and got down almost to me and the SO. She dropped short of us and got the medics on duty that night. From what I remember she didn't really have a leg to stand on and the Doc's DNR was questionable at the very least to all.

I agree RF1, it was one heck of a night.

Mark