Swinging In The Wind

This is an update to my post, "The Misunderstanding," dated April 4, 2009. This situation involved a patient who was made a DNR (Do Not Resuscitate) by mistake. The patient died because when he went into cardiac arrest, we let him die. The family claims that the patient never would have agreed to be a DNR and didn't speak enough English to understand what the doctor said about a DNR. The patient would smile and nod his head just to be polite. The doctor took the nods of the head to mean that the patient wanted to be a DNR.

I don't know if we have been sued yet, but the investigation is still ongoing. One of the administrators called me into his office the other day to discuss the case. He had read my version of the events and wanted to know what I was talking about. He had the computerized chart open and the patient was clearly a full code. I felt like I was in the Twilight Zone.

When the patient had gone into cardiac arrest down in CAT scan, they called me because I was the charge nurse that day. They wanted to know what to do. I told them not to call a code because the patient was a DNR. They soon returned the dead body back to us. The family unfortunately showed up before we had a chance to notify them and found their dad lying dead in his bed. Things went downhill from there.

So, now I'm looking at a chart that shows the patient was a full code and wondering if I have lost my mind. With more confidence than I felt, I said, "He was too a DNR."

One of the great things (and bad things) about our work computers is that you can't entirely erase what happened. We did a search of the order history and discovered that the doctor had deleted the DNR order the day after the patient died. This is evidence that the doctor knew he screwed up and was trying to cover his tracks. He probably didn't give it much thought, but in his haste to protect himself, he left the nurses (and especially me) swinging in the wind. Changing the patient's chart made it look like the nurses just twiddled their thumbs when the patient went into cardiac arrest. Well, in a sense that is what happened, but we did nothing because we had a written order not to call a code.

I should be angry, but my reaction is more astonishment than anything else. It amazes me that the doctor thought he would be able to get away with it. He altered a legal document. If we are sued, the opposing attorney will feel like he has won the lottery when he discovers this.