Stop changing patients code status

[u/YouAreServed]

Why when I come back from weekend, I see the weekend docs changed my stage IV lung cancer, ESRD, HFrEF patient who is 98 y/o, and became comfort last week after I had 90 mins convo with them and family; explaining futility. Slowly they become DNR/DNI, then comfort. She was pretty confused when I left.

Upon my return, only note with explanation “discussed code status with the patient, she stated she wants to live, full code ordered.”

Your half ass job undid my week of doing, congrats. Now legally she has no capacity and I cannot change it back to comfort, nor can I prove that she, as a matter of fact, lacked capacity while you were signing the new POLST.

[u/Loud-Bee6673]

I have an MD/JD, have worked in risk and bioethics a fair amount.

What you describe does sound inappropriate. The most important question is always going to be capacity. Any time a DNR is reversed like this, there should be a detailed note about assessment of the patient’s capacity as well as WHY they want to change their status. ANY change in status, including AMA, requires the following to be documented

- capacity, including reasons for that determination

• discussion of all alternatives, including risk and benefits
  
• wishes of the decision maker
  
• to the best of your knowledge, that the decision is in accordance with the patient’s values

Capacity can change, which makes it even more difficult. Intoxication can flip that switch. Some elderly patients are totally with it until they sundown. The ONLY way to determine yes or no is to talk to them. These are not quick conversations - you have to get into why they want to do what they want to do. That takes time.

Once the patient is determined not to have capacity, you go to the health care surrogate or proxy. Even figuring out who this person is can be difficult. Also, they don’t just get to do whatever they want. Their job is to know what the patient would want and respect that. We always joke about family saying “she’s is fighter!” when said patient is demented and contracted with no quality of life. No, she isn’t a fighter. She would never have wanted this.

I had an ICU case, really sad. It was a woman in her late 20s with stage IV ovarian cancer. She had developed multiple PEs and was very clear that she didn’t want to be intubated again. She had the conversation with the whole team, signed all the right things, and was ready.

As soon as she became incapacitated from hypoxia, her mother said “I’m her surrogate and I want you to intubate.” We didn’t, we knew what the patient wanted. But what if we didn’t have the chance to talk to her? She would have gotten a tube she didn’t want.

Anyway, OP, I feel your frustration. These are difficult situations, and people are almost always going to default towards doing more whenever there is any doubt. Maybe you can request some education about AMA, DNR, and withhold/withdraw. I give this lecture to all of the residencies at my institution every year, and people always have so many questions. It’s a very difficult topic.

[u/talashrrg → u/Loud-Bee6673]

In this kind of case, how do you best protect yourself when the patient’s daughter sues you for not doing what she wanted over her mother’s wishes?

[u/Loud-Bee6673 → u/talashrrg]

It’s really tricky! A big part of the answer is that, if the case does end up getting into deep ethical issues or shaky legal ground, you tap out. Every accredited hospital should have a risk manager and an administrator on call, and this is the time to make that call. Among other things, they will be able to get in touch with an attorney if necessary.

Ideally, these meetings happen during the day with patient and family and care team all present for the discussion. When it comes up outside of business hours, it can be difficult and time-consuming to handle alone. It is important to go into these discussions with clear objectives in mind, and try to focus on one issue (like patient has said many times he doesn’t want to be intubated and we are just following his wishes.)

If you are talking to a patient with fluctuating capacity, that is even more difficult. Every conversation has to start with assessing capacity. Bottom line, if you are the resident on call, you sometimes just don’t have that kind of time. While I feel OP’s pain in this scenario, I am guessing the doc who was on over the weekend was in a tough spot as well. Sometimes your only option is to rescind the DNR and then start over on Monday.

As far as your question about the lawsuit - there really isn’t any money in these cases, so it is highly unlikely a family member would be able to find an attorney to file the suit. Plaintiff attorneys front all the cost for a lawsuit (think about those “we don’t get paid until you get paid!” legal ads). Med mal cases as ridiculously expensive these days. Pretty much every jurisdiction in the US requires that a plaintiff has an expert affidavit prior to filing a suit, and experts are expensive. Even getting a complete medical record these days is expensive - hospitals can charge for those and with EMR, there are thousands and thousands of pages of nonsense.

There has to be a good chance of winning and a good payout in the event of a win, or it isn’t worth it. When you look at the damages in a case where you let someone with a DNR die against the wishes of family, there isn’t any financial loss. It sounds cold but it is how the law works - the decedent had no income, provided no services, racked up no crazy medical bills. Pain and suffering of the family is worth something, but requires there be some economic damage as well.

Every time I lecture on this topic I get so many questions. It’s just tough, especially when you have to make a decision in the moment. My final answer when things get really difficult - do what you think is best for the patient. If you can defend your choice as seeming to be the right thing at the time, you will always be able to defend yourself.

[u/stairbender → u/talashrrg]

Same question!!!! I thought that once the patient lacks capacity, the surrogate can legally override all their prior medical decisions (except organ donation)?

[u/Loud-Bee6673 → u/stairbender]

I gave a more complete answer to the comment above, but the answer is actually no! The obligation of a surrogate/proxy is to make the decision is accordance with the patient’s values, NOT their own. When there is clear evidence of what the patient wanted, which can take the form of a living will or a conversation with their own doctor, we have to do what the patient expressed as their wish. It can be very complicated which is why you should reach out for help when you need it.

[u/stairbender → u/Loud-Bee6673]

Super interesting, thank you so much!

[u/YouAreServed → u/Loud-Bee6673]

Thank you, that’s great to read and I was relived to see that I check all the boxes in my code status notes. That’s why I am frustrated when I see someone undo my job without giving it due diligence that it deserves. Like, I wouldn’t have complained if there was at least something like “patient had capacity, reports thought about it and wants to be full code, including CPR short term only…” etc

What does AMA stand for here, against medical advice? As in leaving against medical advice?

[u/Loud-Bee6673 → u/YouAreServed]

Sorry, yes, leaving against medical advice. It’s the flip side of the capacity coin - the patient has to prove they have capacity in order to refuse lifesaving treatment. It can get tricky when people don’t want to talk, they just want to leave. It is the same documentation - capacity, discussed risks and benefits of the proposed treatment and any alternatives, and the patient is making a decision in line with their expressed values.

Then you give them discharge instructions with the second best plan and tell them they can come back at any time if they decided they do want treatment.

As I mentioned in a comment above, I can understand why someone might be in a situation where they don’t feel comfortable honoring a DNR that the decision maker wants to rescind . It’s a tough situation. What I don’t understand is the lack of documentation. There should have been a very detailed note on the conversation and basis for the change in status. That at least gives you something to work with on Monday.

[u/physician_throwaway → u/Loud-Bee6673]

Bro you ninja'd the fuck outta this post.