End Of Life Never Events: Why?!

My sister is in the medical field. Thank the gods of sanity. She’s in critical care, and she’s damn well smarter than me by a mean streak. We compare notes sometimes, usually after frustrating or traumatic experiences on the clock. It’s nice to have her weigh-in on things; to compare practices and perspectives.

Today, we chatted on the way to a family brunch celebrating relatives in from Sweden. Her husband listening at the wheel, my sister told me about the trials of interdisciplinary relationships that she often faces as a prescribing provider. One particular physician came up; I was saddened to learn of his too-oft practice of going against patients’ Advanced Directives in moments of haste and adrenaline.

I asked my sister if she thought the general pubic realized things like this occurred in hospitals everywhere. Hearing of this MD intubating or coding patients with clear Do Not Resuscitate and Do Not Intubate orders, while sad, was not new to my nurse ears. I’ve seen countless patients – whether by family or physicians – given treatment they wished against over the years.

Many times this happens accidentally, which my sister seemed to sense was the case in her dealings. Situations get heated and panicky, people act quickly, and things are missed. But that’s just it: things are missed. Why is this thing — a patients explicit right to deny treatment — anything less important than their right to any type of treatment?

When a patient goes to the hospital for an amputation of the right leg, for example, and leaves with an accidental amputation of the left, that’s called a sentinel event. Or, to put it a bit more blatantly, a never event. Never, never, never.

When things like this happen, meetings happen. Big ones. Analysis is done of the situational events, and the system failures. In the ideal scenario, things aren’t punitive, but they very urgently and delicately ask the question, “What the $&$!/?&&@ happened?!” and then create safety mechanisms to ensure it never happens again.

I wondered aloud to my sister about this. Why isn’t giving unwanted care to a patient considered as much of a sentinel event as lopping off the wrong leg? Patients with expressed wishes against life support state them for very specific reasons. Often they are in the end stages of their illnesses, wanting care centered upon comfort. Many know exactly what they want and what they don’t want. Some are dying. To prolong their treatment with interventions they specify against, is a violation of their rights as patients, and their dignity as humans.

I’m not writing to say this physician should be punished. I’m musing because it shocks me that while we have safety checklists — time outs — for everything from doing a sterile procedure to brain surgery, in all the years I’ve been a nurse, no one has ever stopped before a code or an intubation and said: ADVANCED DIRECTIVE CHECK?

Seems easy enough. A heck of a lot easier than explaining to the family why their loved one was accidentally cheated out of the course of care, and perhaps even death, they asked for.

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