In my last column (see May issue), I wrote about the obligations of a nurse in honoring the wishes of a dying patient. This month, Ill be covering nursing responsibilities, possible legal consequences and patient advocacy.
Competent and compassionate care for the terminally ill requires a nurse to be familiar with the previously defined legal terms and documents pertaining to end of life decisions including: 1) a living will; 2) designation of health care surrogates; 3) durable power of attorney; and 4) DNR orders.
In this murky area, one thing is clear. Policies and procedures setting forth nursing responsibilities must be in place and followed. Nursing policies and procedures should include the following:
1. frequent staff and interdisciplinary communication regarding advance directives upon admission, transfer, discharge, between shifts and as needed;
2. chart review to determine recent mental status, diagnosis, prognosis and specifics of advance directives, including the identification of the decision maker and determination of DNR status and existence of order in chart.
3. assessment of level of consciousness and mental status;
4. communication with the patient, family members and decision maker regarding the understanding of the illness and advance directives;
5. communication of actual and potential problems to the physician, immediate supervisor and risk manager, specifically including concerns regarding competency, capacity to consent and legal procedures to be followed; and
6. placement of visual cues, which communicate advance directives, e.g. a sticker on the chart, above the bed or on the medication administrative records; or the use of Kardez or an analogous electronic tool.
In short, the principal to bear in mind is good communication helps avoid legal consequences, including a law suit and professional discipline. Fortunately, only one Florida case has been reported where legal action for assault and battery, negligence and violation of rights was taken. In a case of first impression, a West Palm Beach jury recently awarded $150,000 for its staffs negligence for failing to follow advance directives. A 92-year-old Alzheimers patient was intubated contrary to her wishes, resulting in battery, loss of dignity and six days of needless suffering and related medical expenses. Notably, one juror indicated the decision was based upon the impression that the facility did not have policies and procedures in place to prevent such instances.
Professional discipline for failing to honor advance directives is also possible. The Nurse Practice Act requires conformance with prevailing professional standard of care. When there is a violation, the Department of Health has the authority to conduct an investigation to determine whether there is probable cause to take action against a nurses licenses. If there is a finding of probable cause, the Board of Nursing initiates disciplinary proceedings.
The bedside nurse is oftentimes in the best position to identify issues concerning advance directives. In these instances, a nurse has a duty to serve as an advocate, especially for patients who can no longer speak for themselves. It is a nursing responsibility to ensure questions of competency, capacity and consent are resolved and that policies and procedures are followed in conformance with standard of care. The outcome is the rendering of competent and compassionate care and the avoidance of legal consequences. Most importantly, taking such steps allows a patience to die with dignity.
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