How important is it to discuss and clarify with administration and staff what DNR is to reduce conflict between policy and practice?

Tina loves her mother Beverly dearly, however, Beverly’s case of Alzheimer’s is getting worse day by day and she is no longer able to provide Beverly with the treatment she needs. After considering all options available she has made the difficult decision to move her mother to a highly recommended nursing home that specializes in providing patients suffering from Alzheimer with the best care possible. This facility provides both short and long-term care.

When the day arrives for Beverly to be moved to the nursing home, she is not in great condition. They proceed forward with the move and upon arrival, they ensure that Beverly is made comfortable while Alice completes the necessary paperwork. The preparation leading to Beverly’s move has fatigued Tina and she does not complete all the forms but promised to complete them within the next 2 days. Understanding the importance, Tina does ensure to give them Beverly’s advance directive. She explains that if Beverly’s heart stops beating, she did not want to have CPR, surgery, antibiotics, etc. Alice made sure to sign the color-coded DNR order and left the rest of the paperwork for another day when her mind was fresh.

Early the next morning Tina awakens in a fog by the telephone. It is the nursing home. They explain to Tina that Beverly suffered a “cardiac episode” and that 911 was called. Beverly was transported to the local hospital. Tina rushes out of the house to the hospital. When she arrives, she finds that Beverly is in ICU connected to a ventilator, a heart monitor, and has an intravenous line. Tina is furious and searches for the hospitals’ patient representative. Tina doesn’t understand how her mother’s wishes were disregarded and ended up exactly in the opposite position she wanted. “Why wasn’t the advance directive and DNR not followed? “Doesn’t my mother’s wishes mean anything,” she fumed?

What are your thoughts on why the advanced directive and DNR were not respected? Who is at fault for this? Is disciplinary action necessary?

How important is it to discuss and clarify with administration and staff what DNR is to reduce conflict between policy and practice?

The only true way to know what DNR means to a patient and/or patient rep is through discussion on a case by case basis with each patient and/or patient rep. How often do you think this occurs and should this become common policy? What role should the ethics committee play in such a discussion with the patient and/or patient rep?

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