The Misunderstanding

A man is lying dead in the morgue right now, all because of a misunderstanding. The crisis started just as our shift was beginning. Someone called a code blue, so we rushed into the patient's room to do our jobs. The man had stopped breathing during a seizure, but quickly recovered by just being shaken.

At some point, we realized that he was a DNR (Do Not Resuscitate). A code shouldn't have been called, but no harm was done. However, the patient was unstable, so the doctor ordered that the patient be transferred to ICU. His heart rate was almost 200.

No beds were available in ICU. It was going to take some time for ICU to make room for him, so in the meantime, he waited in our unit, with a heart rate of almost 200. We are not a telemetry unit. We have no way to monitor heart rhythms. We only knew how fast his heart was beating.

The doctor wanted a CT scan of the patient's head, so since radiology was available, he was sent there. After that, he was going to go to ICU. Only, he never made it. While radiology had him, they called and asked if we were sure that the patient was a DNR. I said yes. At that point, the patient was in full cardiac arrest. A code was not called. He could have been brought back, I'm sure, but we were following the patient's wishes, we thought.

The body was brought back to us. The family was notified and soon they began arriving. It was a large, grieving family. They were shocked to learn that we had let him die. They said that he never would have agreed to a DNR.

The doctor who ordered the DNR, didn't follow our usual protocol. He didn't write any notes regarding his discussion with the patient. All he did was check a DNR box on the computer. We don't even really know if he intended to check that box.

The family also correctly pointed out that the patient was confused. How can a confused person agree to a DNR? The family was also never consulted by the doctor regarding the patient's wishes. And, perhaps worst of all, the patient spoke almost no English. The patient was a nice man who would politely smile and nod his head in response to almost any question. The doctor never used a translator.

I'm sure that we are going to be sued.