So was almost confronted with an ethical issue last night. Working the overnight and late 70's patient comes into the ED. Has the normal 70's problems but nothing over the top. She's unresponsive and needs to be intubated but she has a signed DNR/DNI form. Clearly states no resuscitation no intubation, hospitalization and medical treatment is ok. She can't respond and really no idea why she's unresponsive. Glucose ok and no response to narcan. 3 daughters are at bedside and after discussion every one of them demand that I intubate. One even says she signed the DNR over a year ago and tells me she would want to be intubated. What do you do and why?
Intubate or don't intubate
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Idk, that's tough. Depends on the situation I guess. Normal vitals/benign exam/low concern for ICH? I'd probably intubate. If it's massive stroke you can always extubate, but if it's an accidental xanax overdose? That's easy to reverse and vent time should be low for a full neuro recovery. If she's floridly septic, dilated pupils, or extremely hypotensive I'd probably venti mask her and hope for the best.
I don't expect patients to know the intricacies of why we intubate for the dozens of reasons we do. I assume they sign a DNI thinking they don't want to be vent dependent for weeks or months. But if it's for a day or two with a good chance of recovery? I try to think of what a reasonable person would want in a given situation and make decisions from there.
What ended up happening?
I don't expect patients to know the intricacies of why we intubate for the dozens of reasons we do. I assume they sign a DNI thinking they don't want to be vent dependent for weeks or months. But if it's for a day or two with a good chance of recovery? I try to think of what a reasonable person would want in a given situation and make decisions from there.
What ended up happening?
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No intubation. The patient's wishes are on paper and it would be hard for them to sue you. I would convince the family not to intubate her, in fact with a signed DNR I wouldn't even bring it up. I would just put face mask oxygen on her and tell them I am making her comfortable per her wishes.
So I want answers to my question without my clinical caveat. After head CT it was obvious she had a massive ischemic stroke. Family then understood it was futile and transferred to comfort care. Still Made me think that in the future in the same situation without such a clear explanation what do I do? She has a signed DNR/DNI but family is present and demands intubation. Where does the law lie? I get it she has a signed document. But she can't make decisions at that time. Does the signed document trump the next of kin? If you intubate could you get sued (probably could). If you don't intubate could you get sued (probably could).
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deleted480308
Patient’s mental status at the time is irrelevant, they made their decision prior with dnr.
You can always get sued. Always, no matter what. But with a clear dnr, I would not be intubating
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I don't know of any case law where a physician was successfully sued for following a patient's legally expressed wishes.
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deleted859535
No intubation. Signed legitimate paperwork trumps family wishes. Would take some incredibly extenuating circumstances to convince me to intubate. Low threshold for risk management getting called.
Simple. Just not easy because of the conflict involved. But simple.
Simple. Just not easy because of the conflict involved. But simple.
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Don't intubate. We have enough people suffering for months or even years on vents in the icu then to the floor before slowly rotting away at mt st elsewhere. Trach, peg, aspiration pna all the time, laying in their own urine and feces, no mental status, family never visits. Thanks but no thanks.
It's a signed dnr/dni, doesn't get any clearer than that.
Primum non nocere
It's a signed dnr/dni, doesn't get any clearer than that.
Primum non nocere
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Were any of the three the power of attorney, or HPOA? That's the only other thing that I would consider.
In this case I certainly wouldn't intubate-- your indication was just "airway protection". You can get away with the rest of your workup (head CT, etc) without putting her o the vent.
This gives you time to feel out the family, figure out what is going on, and stand back and think.
Of course I agree, I don't as a practice override a DNI just because the family arrives.
That said, I did a couple weeks ago-- hypothermic/exposed/septic patient shows up. Baseline fully functional, "young" old. RN staff finds an old DNR/DNI in the records. Signed and still valid in writing. So we resuscitate without violating that. Later family arrives. They explain the patient wanted that DNR torn up-- her intention was not to be a vegetable, or not to have resuscitation if she was found to have metastatic cancer. If she had an acute emergency with a solid chance of recovery, she wanted the full court press at least for a couple days.
There is often such subtly to these advanced directives which are not captured on paper; it may be paternalistic but I try to discover the author's true intentions versus just following the paper when the situation appears to call for it, in a "common sense" manner.
This gives you time to feel out the family, figure out what is going on, and stand back and think.
Of course I agree, I don't as a practice override a DNI just because the family arrives.
That said, I did a couple weeks ago-- hypothermic/exposed/septic patient shows up. Baseline fully functional, "young" old. RN staff finds an old DNR/DNI in the records. Signed and still valid in writing. So we resuscitate without violating that. Later family arrives. They explain the patient wanted that DNR torn up-- her intention was not to be a vegetable, or not to have resuscitation if she was found to have metastatic cancer. If she had an acute emergency with a solid chance of recovery, she wanted the full court press at least for a couple days.
There is often such subtly to these advanced directives which are not captured on paper; it may be paternalistic but I try to discover the author's true intentions versus just following the paper when the situation appears to call for it, in a "common sense" manner.
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That's not paternalistic, that's the right thing to do. Unless there is a deep dive chart review, we often don't know the context of any signed directives. If you have a signed directive but good evidence in the chart later that suggests patient would want full resuscitation, that changes things. If family that knows the patient well (not someone living across the country that never visits) tells you they would want full resuscitation, that changes things. Maybe it's just my location, but most of our families around here are reasonable and are trying to act in their family members best interests. In residency, same geographic area, the vast majority of these patients in the ICU, family would move to comfort cares when things didn't go towards improvement within 1-3 days.
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deleted245139
Was one of them a designated POA?
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That's what I asked up above.
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I'm surprised by these answers. I have seen patients wishes overridden every time when a default poa demands it. My understanding is that default poa overrides paper documentation every time.
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This is most often how it plays out in reality as far as I've seen. I think many people get intubated against their wishes when family gets involved. I try to go with the patient's wishes as much as possible, but it's often not straight forward. As mentioned above, sometimes the dnr/dni was not meant to apply to very temporary measures. If someone has terminal cancer, it likely would be inappropriate to intubate that person. If the person is otherwise healthy and needs a brief period on the vent while recovering from pneumonia, it may be reasonable to intubate and see if the patient improves over the next couple days. They may have signed the dnr/dni to cover more long term or permanent life sustaining measures. The family can often clarify the patient's wishes when not clear.
If it's truly a scenario of the patient's wishes being different than those of family, I would honor the signed document every time.
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But nowhere was it stated that any of the family were POA. Two of us did enquire.
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I've worked in 4 different states and they had identical rules on default poa in the absence of paperwork. If a spouse in the room says intubate I have yet to see a single case where that didnt happen even if the patient was dnr or in a few cases hospice.
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Many families don't know what intubation is. If there is a clear DNR from the patient, then I don't even bring up the intubation question with family.
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Define clear.
Not exactly. Most states* have laws that say that in the absence of a legal power of attorney certain individuals may make healthcare decisions for the patient. This is obviously not a legally binding power of attorney. That is important because there is a twist: the family member or friend is legally obligated to follow the known wishes of the patient, both expressed or implied. If they don't follow the wishes of the patient, then they don't have decision making authority. So if a family member says "intubate" and the patient has signed a document that says "don't intubate", then the family member is not allowed to act as a "surrogate." It also applies to implied wishes. For example if a patient is a life-long Jehovah's Witness, and the family member says "give a transfusion" that is in violation of an implied wish.
So you can't say that a "default poa" overrides "paper documentation", because the moment the "default poa" attempts to override the previously expressed wish of the patient (documentation), they almost like magic stop having a "default poa" (or being a surrogate, or whatever they are called where you work.)
*As with everything, every state is different.
However, I will freely admit that reality can be different. Good judgement trumps everything... usually. That is why I am not worried about being replaced by a robot, there are too many things where you follow the rule...until you don't
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- Signed DNR form with appropriate boxes refusing care checked
- Verbalization from family/patient that they do not want to be intubated
- Prior chart with discussion of patient's wishes, and documentation of prior DNR
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Works for me, that's clear documentation. Just wanted to clarify that thought process for any newer learners.
My first inclination was that it doesn't get more clear than a signed DNR... then I remembered about all the DNR/DNI consents I've done as an intern, and how a sizable percentage of patients are not medically literate to understand truly even with a thorough explanation. And of course I have co-interns and others who just blow through the form quickly to get it done, so the nuance of intubation for limited period with optimistic prognosis vs extended and futile may not have been relayed. Not to mention the prevalence of elder financial exploitation by adult children and others, not knowing the circumstances/duress under which the DNR was signed, etc.
Within reason, what has served me well in my career so far would be to do what I thought is right. Not to superimpose my beliefs on those of the patient or family per se. But if I can't defend my actions to myself, then I couldn't look a family in the eye and say that I've done everything I could. I'd rather be sued for doing what I thought was best for the patient than legally protected and conflicted.
Within reason, what has served me well in my career so far would be to do what I thought is right. Not to superimpose my beliefs on those of the patient or family per se. But if I can't defend my actions to myself, then I couldn't look a family in the eye and say that I've done everything I could. I'd rather be sued for doing what I thought was best for the patient than legally protected and conflicted.
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Your career as a medical student? You haven't been sued yet which is why you can discuss it so blithely
A signed DNR form? Intubate, then decide later. DNR =/= DNI. To me DNR = CPR. I’ve known cases where the patient doesn’t want to be starved from oxygen, but is ok dying.
A signed DNR/DNI form? Don’t intubate. There’s a legal form that tells you not to intubate, so you follow it. That said if I know it’s a case where they just need to be intubated for a day, like say they’re just retaining too much CO2, or it’s an overdose of benzo’s + alcohol, sure, I’ll ignore it those times w/ family permission.
A signed DNR/DNI form? Don’t intubate. There’s a legal form that tells you not to intubate, so you follow it. That said if I know it’s a case where they just need to be intubated for a day, like say they’re just retaining too much CO2, or it’s an overdose of benzo’s + alcohol, sure, I’ll ignore it those times w/ family permission.
Sorry I didn't get back on here. A few people have asked about if one was the designated POA. I'm not sure. I was able to get to CT before I started probing that. I guess I was functioning on the next of kin. Before I was able to delve into that it was clear this was a terminal event and family was in agreement that intubation would be futile.
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I hate these cases.
If there's any confusion regarding the DNR, I always err on the conservative side and will intubate/etc.. and let the ICU sort it out. It's difficult when you have immediate family present insisting on intubation. It's easy for them to claim the pt didn't understand it, didn't sign it, claim they are POA when another family member that isn't present is listed as POA and helped sign the form, etc, etc.. It's not worth letting someone die in front of you only to find out later that there was some error in the obtainment of the DNR form or having to deal with an irate family member telling hospital administration that you let their loved one die in front of them without a potentially life saving measure in the context of uncertainty regarding the DNR. It's almost impossible to sort out the confusion in a critical moment like that with limited information + confused/emotional family members. I have a hard time believing you could ever be found at fault in a situation where you made a decision to intervene because you thought it was best for the pt with the limited information you had in the moment. Just be sure to document.
When it's clear cut, I follow the DNR. Most of the time, it's clear cut but occasionally...not so much. I also think there is an art to handling these cases and I have my own approach to talking with the family and can usually talk them down.
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Not a lawyer, but from what I recall being told by one is that the answer to this question (who wins: legal representative/next of kin/healthcare proxy vs DNR/living will etc) varies by state. In New York, you go with what the healthcare proxy has to say over what has been documented. The logic being is that everything has to be interpreted in context, and the patient's representative might very well have a better understanding of what the patient would want given the specifics of the situation. So if you've explained the situation to them, pointed out that the patient has previously indicated in writing that at least at one point in the past they did not want to be intubated, and the risks (not being able to extubate them), you should take the daughters' wishes as if they were the patient's (unless you had some reason to think they are acting in bad faith).
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I think the whole point of having these is so that they're followed, right? Unless the family can come up with some reason to believe the forms are invalid, or there's a newer updated one that shows something else, or some other reason to discard it, I think you follow it.
That being said, does the form say "No bipap"? No oxygen at all? IV fluids, yes or no? I've seen some that say, "Intubation okay, but defibrillation isn't," others that say the "defibrillation is okay, intubation isn't, but IV fluids are okay" and various other combinations that make no sense at all. There are even reports of people having "Do Not Resuscitate" tattooed on their chest, then family shows up and says, "Do everything!" What the heck do you do there?
Some DNR's are vague. Some are more specific. Also, remember, "DNR" doesn't mean "not treatment at all" it only means what it specifically says and you cannot assume anything beyond what's specifically written. That's why it's best that these forms are as specific as possible. There's a whole spectrum of quality and specificity on these forms.
Start with a vaguely worded DNR. Add two cups of medical futility. Then mix in a sprinkling of emotionally distraught family members with layers upon layers of familial baggage. Stir in their varying beliefs, philosophies and educational levels. Add uncle Jim who drinks too much when he's under stress, and his short fuse. Bake at 330 am and you've got a perfectly sticky and uncomfortable bowl of ethical dissonance.
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I'd intubate, then let them pull the plug tomorrow. You're much more likely to be sued for inaction than action. Daughters say she changed her mind since the last time the DNR/DNI form was signed.
Chances are 70 yo grandma isn't going to sue you for saving her life.
Chances are the daughters will sue you for allowing her to die.
What are you going to believe, a piece of paper or 3 humans sitting in front of you? Plus, you have no idea why she's unresponsive. She'll probably just wake up in a day or two.
Easy case --> intubate every time.
Chances are 70 yo grandma isn't going to sue you for saving her life.
Chances are the daughters will sue you for allowing her to die.
What are you going to believe, a piece of paper or 3 humans sitting in front of you? Plus, you have no idea why she's unresponsive. She'll probably just wake up in a day or two.
Easy case --> intubate every time.
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deleted109597
I mean, the healthcare dollars towards those weeks in the ICU are just free money, right?
I'm probably butchering it, but in SMACC there's a quote that goes "Never let a 30 minute conversation prevent someone from dying weeks later in the ICU"
I'm probably butchering it, but in SMACC there's a quote that goes "Never let a 30 minute conversation prevent someone from dying weeks later in the ICU"
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Jolly good, mate.
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If I practiced in the UK then I would follow those rules. However, I practice in the US. The rules are less clear. Much like ACS Risk Stratefication, I would treat this as Angry Family Member Lawsuit Risk Stratification and would err on the side of intubation with extubation and death in the ICU after the family has said their good-byes.
Correct me if I'm wrong: In England if you sue someone and lose you have to pay their lawyer fees. :O
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Yeah but who is going to press charges in that situation? The patient, who is either dead, comatose, or alive (because you intubated him/her)? The family who was making you go against the DNR in the first place?
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Family would, absolutely. I would not at all be surprised if the family member said "you had the documentation, you knew what my mother's wishes were, and I was obviously emotionally distraught, so you shouldn't have listened to me, you should have followed the DNR/DNI." I could also see judges and juries in certain jurisdictions here fall for that argument. Anything for a big payday.
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Maybe I'm under-rested or over-stressed, but I am really bothered by how often the threads on here that start out discussing patient care decisions devolve into us speculating on the likelihood of getting sued.
Now, I don't want to get sued, and I do take steps to avoid it, but it is NOT the deciding factor in the vast majority of cases. I see two main reasons for feeling this way:
1 - I became a doctor because I was good at science and I had a strong sense of ethics. Those are the tools I should be applying in most cases.
2 - I am not a lawyer and I know very little about tort law. I suspect that's more often than not true for EM docs. So when doctors make decisions based on expected legal outcomes, it's the blind leading the blind.
Sure, document defensively and don't be cavalier. But if you're intubating non-salvageable DNR patients because you're afraid to get sued, then you're being an a$$hat and you're might not even be protecting yourself.
Now, I don't want to get sued, and I do take steps to avoid it, but it is NOT the deciding factor in the vast majority of cases. I see two main reasons for feeling this way:
1 - I became a doctor because I was good at science and I had a strong sense of ethics. Those are the tools I should be applying in most cases.
2 - I am not a lawyer and I know very little about tort law. I suspect that's more often than not true for EM docs. So when doctors make decisions based on expected legal outcomes, it's the blind leading the blind.
Sure, document defensively and don't be cavalier. But if you're intubating non-salvageable DNR patients because you're afraid to get sued, then you're being an a$$hat and you're might not even be protecting yourself.
Bam! - definately true. I think you could probably fix a hell of a lot of your legal issues if you changed that.
To the best of my knowledge no doctor has ever been sued for saving a patients life. We do however have a hell of a lot of legal backing for doing what ends up to be the right thing for the patient.
My hospital pays every single penny of any lawsuit taken against me but I pay $2000 per year to a medical defence organisation who give me top class legal back up.
To the best of my knowledge no doctor has ever been sued for saving a patients life. We do however have a hell of a lot of legal backing for doing what ends up to be the right thing for the patient.
My hospital pays every single penny of any lawsuit taken against me but I pay $2000 per year to a medical defence organisation who give me top class legal back up.
An important distinction: prosecutors press charges, citizens don't. So what the family wants is basically irrelevant in a criminal case. What matters is if the prosecutor is planning a run for Senate and is interested in some free advertising.
The Patients Were Saved. That’s Why the Families Are Suing.
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I currently work as a tech in the ER...I can't tell you how many times I've had to start compressions on a patient who purposefully signed a DNR and the POA rescinded it. Crushing a 90 year old chest while they are asystole is ridiculous and frustrates the heck out of me.
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All. The. Time. Here.
The vast majority of my patients are 80+.
They code frequently.
[Street Fighter II joke]
(Insert Coin)
***HERE COMES A NEW CHALLENGER***
*Down, Down-Forward, Forward + Punch* = DO EVERYTHING YOU CAN TO SAVE MY GRANDMOTHER WHO I HAVEN'T SEEN IN 10+ YEARS!
Grandma intubated! ROSC achieved!
YOU LOSE!
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deleted859535
Then you go out into the parking lot and beat the **** out of a car, right?
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If only.
Standing axe-kicks are the best way to win that stage if you're playing Ken/Ryu... which, are the only options if you ask me.
I've seen *******es try to Sho-Ryuu-Ken their way thru the car.
If you're going to be frame-perfect, then... you're wrong.
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DNR/DNI is a guide for what the pt wishes, but if POA/medical power of attorney wishes to reverse it after discussion about DNR/DNI, then you intubate- at least in my state. Much discussion of course goes in to avoiding the intubation and using strong language about causing more suffering, going against the pt wishes at the time the DNR was made and likely will have a significant decline from their prior “baseline” IF they ever get non-terminally extubated.
I always like telling them - not doing something is doing something. Modern medicine can keep people “alive” indefinitely, which is not always a good thing.
We’ve all seen the hospice pt come in who then gets reversed - which is really a case of poor communication with expectations regarding clinical features/decline and poor overall management prior to coming in to the hospital.
I always like telling them - not doing something is doing something. Modern medicine can keep people “alive” indefinitely, which is not always a good thing.
We’ve all seen the hospice pt come in who then gets reversed - which is really a case of poor communication with expectations regarding clinical features/decline and poor overall management prior to coming in to the hospital.
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Except that in the context of the ED that 30min conversation is probably going to cost you whatever chance you had to resuscitate the patient which looks bad if family ultimately decides you should keep patient alive. It usually takes a minimum of 30 min to 2 hrs just to get all the stakeholders up to speed, let alone come to consensus. In the ICU... I agree fully.
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deleted109597
It's much, much harder to undo intubation than it is to prevent it. Yeah, we are stuck in a tough place, but we need to make the right decisions too.
