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.
Written by Melissa on 12:05 AM
Me
Melissa blogging from sunny Santa Clarita, Southern California, United States.
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7 Comments:
Now I've heard everything - cause of death, "clerical error." Yikes.
Wejust had a "misunderstanding" in our family. My poor father went to his dotor MOnday morning c/o stomach pain and "throwing up something that seemd it should be coming out the other end". Those were the words my daddy told his doctor. His doctor gave him an Rx for reflux medication and sent him on out the door.
Within hours, daddy is in so much pain he goes to the er. Long storey shor after staying in the er for10 hours and then waiting on a surgeon for 4, he was finally hav surgery for an intestional obstruction. During this surgery he aspirated and developed aspiration pnumonia. He has been in ICU now almost a week.
My dadddy at 76 was healthy, worked out at his gym several days a week, ran, still worked a job, did his own yardwork, housework, etc. Now he is lying in a bed trying to breathe. Last night, they said his heart went into afib.
Do I blame his family doctor? You're damned straight I do. He had been going to him for weeks complaining of stomach problems. All he kept telling him was reflux, reflux.
I am so angry about this "mistake" I can hardly see straight.
I wish people would start seeing that doctors do not deserve the respect they are immediately given simply because of the title "Dr."
They are human, like us.....often times with a big ego and not very much knowledge. There are many times I wish I could tell patients what I really think of their doctors at the hospital...but as nurses, we're not allowed to say anything.
That sucks about your patient dying. It's likely the hospital will settle, because it sounds as though they are at fault. It still amazes me that a doctor writing "DNR" or choosing that option on a computer is all that needs to be done. We have patients sign consents for blood, tests, surgery...but not a consent for DNR? It needs to be changed.
Sometimes its difficult for hospital nurses to prevent doctors from killing some of the patients.
Where I work, even a DNR patient would have gotten a Cardizem or Amiodarone drip going. That's what Tele is for. The CT could have waited until the patient was fucking stable.
That's probably a lawsuit alright. 7 figures.
Connie, clerical error is a surprisingly common cause of death. Yikes is right.
Surgeon, I'm sorry about what happened to your dad. I hope that he's doing better now.
Jen, that is a great idea to have patients sign DNR forms. We would never take a patient to surgery without a written consent, so why is it okay to let people die without something in writing?
Dr. Jacobson, thak you for visiting. I will visit you soon as well.
Shrimplate, the family has decided not to sue. The patient had terminal cancer and the family is now thankful that he died suddenly from cardiac arrest, rather than a slow, painful death from cancer. Are we lucky or what?
Wow, what a sad story. I am sorry to hear about that, hope all is well.
Ecrunner, thanks. I'm managing. There is an update on the post dated 6/2/09.
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