Ethical question: to tube or not to tube?

[Doczilla]

41 YO F presents to the ED in status epilepticus due to profound hypoglycemia. She has a history of type I diabetes as well as multiple sclerosis. She functions independently at home, but has maxed out therapy for the MS, which has been progressive.

The patient was last seen normal by her husband about 3 hours ago when he went out to run an errand. When he returned, he found her unconscious. Accucheck read "low", so he gave her 2mg of glucagon IM and called paramedics. Blood sugar done by EMS read 113, though we think this may have been a spurious reading by the meter. Nothing suspicious was found such as a suicide note or empty pill bottles.

She is on an insulin pump, which appears to be functioning well and is not empty. She gets 2mg ativan IV and D50, which stop the seizures. She never regains consciousness in the ER. In fact, she requires multiple doses of D50 and a D10 drip to maintain her blood sugar.

Here's the kicker: she has a DNR order, which the husband produces from 2007 (DNR orders in Ohio do not expire). He, and her father (both at the bedside), state that the patient had explicitly stated that she would not want mechanical ventilation, CPR, or defibrillation at any time, and was quite adamant about it. The DNR form does not specify what treatments can and cannot be performed, simply to not resuscitate in case of arrest. No mention on the standardized form about intubation or any other measures.

I'll tell you later about what happened with her.

I got into a discussion with a couple of the nurses about what to do with her. I did not think that intubation was appropriate, as we had an (albeit old) DNR form and two close family members that said she would not want it. The nurses said that she is young, still very functional and relatively healthy, so why would we not intubate or resuscitate her if needed? I cited two chronic, progressive, debilitating diseases, although I concede she is not bed bound or demented. They brought up the fact that the husband may be stretching the truth for his own purpose, i.e., to rid himself of her. They brought up the possibility that he may have given her an intentional OD of insulin, though at the present time there is no evidence of foul play. She is currently maximized on therapy for the MS, and in fact exceeding typical doses of her medication (not illicitly, but with doctor's order) to try to slow the progression.

So, if it is medically appropriate (i.e., for airway protection, need for ventilation) do you intubate her?

I am not concerned with discussing details of her treatment right now, only the ethical question of intubating or defibrillating her if it becomes necessary.

'zilla

[PedOncoDoc]

With a DNR order, and both her husband and father stating she would not want rescucitation, I would not intubate her. In fact, once the DNR order was produced, I feel it would be unethical - and possibly illegal - to intubate her.

I feel the nurses were out of line in making accusations of the husband (especially when the woman's father supported the decision as well) and made assumptions about the wife's quality of life.

So what happened?

[Red Flag 1]

Agreed.

[swatsurgeon]

No intubation for sure, as far as the nurse stating that she's young, etc, have her review the two cases of wrongful life: successful lawsuits against medical personnel that wrongfully resuscitated patients out of a paternalistic need to intervene when there were written advanced directives and orders to do no resuscitative maneuvers. Both were in the 10's of millions against the medical personnel/hospitals, etc., and in my opinion were appropriate lawsuits.

When faced with these issues, as long as no documentation is in evidence, do all appropriate medically indicated treatments, they can always be withdrawn when a durable DNR order is uncovered or an advanced directive is produced. The withholding or withdrawal of artificail medical support are one and the same as per the courts so not starting something or removing an intervention or therapy is viewed as the same and appropriate when orders exist to remove/stop/not initiate said therapy.

If she regains consciousness and says stop all Tx's, then make sure her family is at bedside so they see it and then document it and stop all Tx's....we do it all of the time.....and feel good about being able to follow the wishes of the patient, NOT the wishes of the family. It is always a matter between patient and physician, the family is hopefully representing the wishes of the patient, not their own.

ss

[Doc Diego]

Very unusual. Someone who faces their own mortality and quality of life issues head on and institutes a DNR order. Don't see that enough where I work(on an ambulance). Sounds like the nurses you work with are somewhat inexperienced (or love drama). A DNR is a DNR.

[JAGeorgia]

Disclaimer: I am not a attorney. This is not legal advice.

An Advance Directive is exactly that! It is not a Power of Attorney for medical treatment so the alleged motives of the husband/father are irrelavant.

Intubation/trach/cric to maintain an airway on a DNR patient? To what end? Find a manequin if you want to practice or spend time saving someone's life who wants to be saved. This lady MADE THE DECISSION. Have enough respect and honor to follow her wishes.

IMHO: It may not always be easy but it's right.

[Cynic]

Speaking as a nurse, I feel those nurses were out of line. They were not respecting the wishes of the patient. They may have been identifying with the woman and projecting what they would want for themselves or as someone pointed out, they love drama.
In any case I'm glad you did not intubate.

[zeromedic]

I am in agreement with SS...as long as the DNR is valid (no expiration date is a bit odd, but every state is different) then you have to respect her wishes...as far as the whole intentional OD by the husband theory, it would make a great TV drama but unless there is any evidence of it nothings going to happen...so I say no tube

[CSB]

Disclaimer: I am not a attorney. This is not legal advice.

I am an attorney. This is legal advice.

A DNR order is a direct order from your boss, the patient.

If you do anything contrary to your patient's express instructions, you are substituting your desire/wants/needs for the free will of your patient.
And that is wrong.


(I realize that the case is probably "over" by now).

[JJ_BPK]

A Short Story..

My FiL was in for a bi-pass. He was 79 yo and had a 15 yr history of heart problems including a 12 yo pig value that was at end of the trail. He had lost his wife of 59 yrs 6 months earlier and was in decline. He knew it, we knew it, the priest knew it.

He had a DNR prepared at Admittance (hospital spicific, state format). It followed him thru the OR and CICU, no problems.

The day they moved him to semi-private he went into cardiac failure. The wife was there, called me and the priest.

When the monitor beeped for the last, the floor nurse rushes in and wants to re-sus.

We told her there was a DNR and blocked her access.

Nurse starts yelling for security and climbing over the bed to get to Dad...

My wife went hysterical and I went ballistic..

The Super shows just as I am about to pop missy nurse in the nose.

As I stop to explain why I was going to pop the nurse, she starts yelling she didn't care because the order was not in her hands. As if she had the final say..

I cocked back the hammer and the Super said Please Stop, there is no need,, She knew the order was coming up from CICU.

The nurse still didn't want to stop.. Two other floor nurses held her back from getting a good pop..

This was in Florida 18 yrs ago..

It was as close as I ever want to get to going to jail,, But I would have...

End Story..

[Saturation]

I believe it is quite meaningful to this case that a 41 YO had a signed DNR from several years ago.

I explain and assist people signing DNR's almost every day in my work. It has been my experience that the younger struggle with signing such a form. The more elderly and sickly are quick to sign and sometimes joke/comment "I didn't have this already?!"

She signed the form and she apparently discussed her wishes with the two involved and clearly interested men in her life. Mechanical ventilation/intubation is a routine part of my DNR discussion but you're right - not part of the form. (FL DNR does not expire either).

As an aside- most conflicts that I have been a part of or read about in the take off supportive measures/keep supportive measures have been spouse v. parent. The remainder tend to be sibling v sibling with only a very few parent v. adult child

[Saturation]

Originally Posted by JJ_BPK

A Short Story..

....

This was in Florida 18 yrs ago..

It was as close as I ever want to get to going to jail,, But I would have...

End Story..

DESPICABLE and you had every right to report her to State of FL licensing board (and more )!

I can't say that would never happen again now 18 years later though. I have witnessed too many 'professionals' placing their values into a situation creating great needless drama. I have in fact threatened bodily harm to a worker that tried to talk a Veteran out of what he wanted for his medical care.

[swatsurgeon]

IMHO, one of the greatest problems with advanced directives/living wills is how generic they are....."if I have a terminal condition...." I developed one that is scenerio or diagnosis specific and I have given it out to over 600-700+ people. If anyone would like a copy by email just let me know. Most are difficult to interpret as we saw in an above post...DNR comes in many flavors and as the doc reading and trying to understand what the patient wants without the luxury of discussng it with the patient while they are rational, calm, mentally able, I have to read them and try to understand what they meant by their generic DNR or adavanced directive or living will. Usually, families are less than capable or helpful with the interpretation.

There is never an excuse for a health care provider to not know the status (DNR, DNI) of a patient. This is where the wrongful life suit comes into play. They have to know, whether by arm band, chart label/sticker, or what ever means that particular hospital uses, but if a patient is wrongly resuscitated, there should be hell to pay because you have crossed the line of patient trust in their health care providers. We always want to do what is asked of us (if it is reasonable) to fulfill a trust that the patient has in us, we (I) never want to violate that trust, it is too sacred.

ss

[Counsel]

Here’s your second legal opinion. What CSB is completely correct.

From your first post it looks like the physician would be substituting the patient’s request in the DNR order for that of the nurses and all of their speculations/theories. If you had the time, try to get an “on the spot - first hand” legal opinion by the “in house” counsel or the like. I know that not many have the “timbales” to make such a quick decision as it would be needed, but still, give them a shot. In any case, not following the DNR, base on assumptions, is not recommendable for the treating physician and/or the Hospital if she entered trough the ER. They will be exposing themselves to liability for damages.

[Red Flag 1]

tattoo "DNR" in bold letters across his chest.written orders for DNR.

RF 1