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Mr Daniels is an 89-year-old male with a history of COPD, hypertension, and coronary artery disease. He is admitted to the ICU for acute respiratory failure due to exacerbation of his COPD. He requires intubation and mechanical ventilation. The day after admission, his wife presents evidence of a universal DNR order form. After discussing this with the health care team, it is decided to maintain the current treatment plan of intubation and mechanical ventilation. The patient's son, who was previously appointed the patient's health care power of attorney, disagrees with this decision. He would like the patient to be extubated, removed from mechanical ventilation, and allowed to pass away from natural causes. Before a treatment plan decision is ultimately reached, the patient suffers cardiac arrest and is unable to be revived. The patient is pronounced dead by his attending physician.

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1. Was the code status clearly determined?

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2. Who is allowed to make health care decisions for this patient?

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3. Who may pronounce this patient dead?

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Answers

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  1. This case is an example of common scenarios that arise when taking care of critically ill patients and dealing with end-of-life decisions. The patient's previous wishes were stated by the universal DNR order form. This should have been verified at admission, before the patient was initially intubated.

  2. Because the patient's son was the health care power of attorney, he had the right to make medical decisions over the patient's wife.

  3. The attending physician is allowed to pronounce this patient deceased.

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Code Status and Death

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This chapter will discuss areas of health care that are tied to laws and regulations. These may differ from state to state. It is important to understand the rules of the state in which one practices medicine. Unless otherwise stated, general comments in this chapter will be based on reference to Illinois law.

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Code Status

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All patients interacting with the health care system should ideally have their code status determined. It is important to determine this prior to a cardiopulmonary arrest situation so that the patient's wishes may be fulfilled during a catastrophic event. Performing CPR and life-sustaining measures on a patient who has previously decided against these may be grounds for criminal consequences.

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One should approach code status determination as “all-or-none.” It is not generally recommended to provide the different treatment options during a code situation as individual decision points. Certain patient scenarios will make the “all-or-none” stance more difficult. For instance, a patient with COPD who has previously been intubated may feel very strongly about never being intubated again. On the other hand, the patient may elect for full cardiac resuscitation during a potentially fatal heart attack. It is extremely important to have candid and upfront conversations with all ...

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