Mr. Jones is a 92 year old gentleman with acute congestive heart failure. He has a long list of comorbidities, and his prognosis is guarded. Upon discussion with Mr. Jones’ family members present, the medical resident documents a “do not resuscitate decision” in the electronic record on day one of hospitalization. On day three of hospitalization, Mr. Jones’ daughter, named as agent in Mr. Jones’ durable medical power of attorney, arrives from out of town and speaks to the attending physician, asking him to cancel the DNR order and resuscitate, if necessary. This is handwritten in the progress notes, which are scanned into the electronic record, but the electronic field where DNR orders are documented is not changed. In addition, in the daily progress notes entered by the medical resident, the day one discussion resulting in the DNR order continues to be copied and pasted into the record each day, making it appear that the DNR order is still in force. Mr. Jones’ son disagrees with the daughter’s decision and feels it was uninformed; he complains that he (as a registered nurse) was in a better position to make the correct decision. Unfortunately, on day 5 of hospitalization, Mr. Jones’ condition deteriorates and he has a cardiac arrest. “Code Blue” is called by the nurse on duty, and the team arrives to begin resuscitation. Shortly after they begin, the unit clerk enters the room and tells the team that “this patient is DNR.” Resuscitation is canceled and Mr. Jones dies.
- Who had authority to decide whether Mr. Jones should be resuscitated? Is any information that is necessary to answer this question missing from the scenario? If so, what else must be known to answer this question.
- Who should be responsible for documenting DNR decisions?
- What should happen if a record reflects conflicting documentation?
- Are there circumstances in which family members should NOT be allowed to make DNR decisions on behalf of a patient?
- How did the format and capabilities of the electronic record contribute to the confusion in this case? What could be done to address those problems?
Each of these questions should be answered should be at least a paragraph.
Expert Solution Preview
Introduction:
As a medical professor, it is important to teach medical college students about end-of-life decisions and the legal and ethical aspects surrounding them. The scenario of Mr. Jones raises important questions about who has the authority to decide on resuscitation, who should document DNR decisions, how conflicting documentation should be handled, circumstances in which family members should not make DNR decisions and how the electronic record can contribute to confusion.
1. Who had authority to decide whether Mr. Jones should be resuscitated? Is any information that is necessary to answer this question missing from the scenario? If so, what else must be known to answer this question?
The daughter, named as an agent in Mr. Jones’ durable medical power of attorney, had the authority to make decisions about resuscitation. However, it is unclear whether the daughter was aware of the existing DNR order or had discussed it with her father. It is also unclear whether the son had any legal authority to make decisions for Mr. Jones. The hospital could have clarified the legal authority of family members to make decisions for Mr. Jones, and physicians should have ensured that they had the latest information from family members about their wishes.
2. Who should be responsible for documenting DNR decisions?
Physicians should be responsible for documenting DNR decisions in the medical record. Clear and accurate documentation helps ensure that the patient’s wishes are followed, and that all healthcare providers have access to the same information.
3. What should happen if a record reflects conflicting documentation?
Conflicting documentation should be reviewed and resolved as soon as possible by the healthcare team. This may involve discussions with family members and updating the medical record. Conflicting documentation can lead to confusion and potentially harmful medical errors, and so it is important to address them promptly.
4. Are there circumstances in which family members should NOT be allowed to make DNR decisions on behalf of a patient?
In general, family members should be allowed to make DNR decisions on behalf of a patient unless there is evidence of abuse, neglect or exploitation. However, if there are competing interests or disagreements among family members, physicians may need to consult an ethics committee or the court system to ensure that the patient’s wishes are respected.
5. How did the format and capabilities of the electronic record contribute to the confusion in this case? What could be done to address those problems?
The electronic record was not updated with the daughter’s request to cancel the DNR order, and the medical resident continued to copy and paste the old information into the daily notes. This led to confusion among healthcare providers and ultimately resulted in Mr. Jones’ death. To address these problems, physicians should be trained to use electronic records effectively and accurately, and communication protocols should be established to ensure that electronic records are updated in a timely manner. Additionally, efforts should be made to increase the usability and intuitive design of electronic records to reduce the risk of errors and miscommunication.
