Patient’s Wishes and Dying with Dignity
Submitted by Kalyn Woodington RN
The time was seven A.M. and I am out of my element on another unit. To be honest I can’t remember if I floated or picked up overtime to help out. I do remember receiving report on this particular patient and looking at him. I was already thinking, “Oh man, not looking so good, going down fast.” The patient we will call Mr. D. was in the quiet corner room. He was an African American male in his seventies who had been in and out of the hospital multiples time for several issues over the last few years. He laid by himself in the dark quiet room, only the sound of the bipap machine in the background. He was still and his color was very dusky. I was not familiar with this patient nor had I ever been his nurse but he had been to this particular unit before. He was what they called a frequent flyer.
On my assessment with the night nurse, Mr. D is responsive to pain only and obviously very lethargic. His legs are cool to the touch and you can see the evidence of PVD and possibly cellulitis. The pulse ox probe is on his ear and not reading. All extremities were cool to touch and I was unable to palpate pulses on his feet. I did feel his popliteal pulse. I quickly familiarized myself with his chart, and diagnoses. His list of diagnoses was extensive and included congestive heart failure, chronic obstructive pulmonary disease, diabetes, end stage renal disease, and perephial vascular disease. After looking over labs that were done around 6am, the blood gas is marginal at best for his oxygenation but the critical care team is aware and holding off on intubation and aggressive measures until family can be reached. I eventually am able to get a pulse ox reading after about 2 hours, stuck to his forehead – 90%. I will take it.
Mr. D was being followed by several teams including the palliative care team. Upon contacting them I find out that on a previous admission the month prior he had a discussion with the palliative care team and decided to make himself a DNR/DNI. “Oh great,” I was thinking, as in my experiences most of my patients don’t get to talk about these things before they get to a point where they are unable to make their own decisions. Apparently this patient had gone home with hospice but someone had called an ambulance. No children, siblings or surrogate were listed in the chart. After discussing the patient at length with the ICU team, orders for arterial Doppler’s and repeat ABG around noon were given. We were not officially comfort measures but at least a DNR order was instated.
After the palliative care made rounds on the afternoon shift, they were able to get a hold of Mr. D’s only relative: a niece who was not close with him but apparently had called the ambulance for him to come to the hospital. The team had a conference via the telephone with her and discussed that he was terminally ill and that his wishes were previously established and requested comfort measures for Mr. D. She, however, did not agree with what he wanted and was requesting to rescind the DNI/DNR.
I have been in nursing for a long time and have seen families hold on to their loved ones but I have never been in the situation where the patient had already established their desires legally. I watched as the physician explained that they would not go against what Mr. D wanted and would not rescind the DNR as she was not even listed on the paperwork. I strongly believe that Mr. D was suffering and endstage in his diseases. Everyone on the care team agreed that he should have comfort measures. I was very proud of the team for standing up for what my patient wanted, as I usually see the opposite on my own unit where overly aggressive measures are the norm. By the end of my shift, the patient was still a DNR/DNI and the palliative team was talking of a meeting with ethics the next day. To this day I am not sure exactly what happened but I know the patient passed away within a week on the unit.