Comfort Care Request Without a Written Order
At 02:10 on a 30-bed medical unit, you are the charge nurse for a 78-year-old woman with advanced dementia admitted 2 days ago with aspiration pneumonia. Her daughter is her documented health care agent under a signed proxy; the patient has no written advance directive. The patient is now tachypneic at 34/min, SpO2 86% on 4 L/min nasal cannula, BP 84/48, mottled knees, and responds only to painful stimuli. The daughter says, "Do everything-she's a fighter." The attending is not answering; the covering resident says by phone, "Just make her comfort measures only and I'll sign the DNR in the morning." Unit policy requires a physician order for DNR and, when no written directive exists, a second clinician review before withholding CPR. There is no rapid response team; ICU has one bed but the family has not consented to transfer. The resident sounds rushed and says, "You're the nurse, you decide."
1. Identify the legal and ethical conflicts in this situation and the actions you would take in the next 30 minutes. Explain your reasoning.
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The core conflict is between the daughter's request for full treatment, the resident's verbal suggestion of comfort-only care, and the absence of a valid written DNR order. A nurse cannot create a DNR status by accepting a rushed phone instruction, especially when unit policy requires a physician order and second clinician review. The patient's proxy can make decisions using the patient's known values, but the proxy does not have authority to demand treatments that clinicians judge futile without going through the organization's conflict-resolution process.
Immediate actions:
- Treat the patient's distress: position for comfort, suction if needed, provide prescribed oxygen, and give analgesics or anxiolytics only under existing orders or after provider authorization.
- Call the attending again and, if unavailable, ask the resident to document a formal order consistent with policy or escalate to the on-call attending and nursing supervisor.
- Request the second clinician review required by policy before any limitation of CPR.
- If the patient arrests before a valid DNR order exists, begin CPR under policy and call for help; do not withhold resuscitation based on an informal phone comment.
- Notify risk management or the administrator on call if the resident continues to pressure you to act outside policy.
Reasoning: the safest path is to continue emergency treatment and comfort care while obtaining a valid order, rather than letting a verbal comment convert an unsettled situation into an irreversible decision.
2. What would you say to the daughter and to the resident? Include how you would document the conversation.
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To the daughter: use plain language and acknowledge emotion first. "I can hear that you want everything done for your mother, and I am not abandoning her. Right now she is working hard to breathe and her blood pressure is low. I need to know what she would have wanted if she could tell us. Did she ever talk with you about being on a breathing machine or having CPR?" Explain that comfort care means treating pain, breathlessness, and agitation, not withholding all care. Avoid promising that everything medically possible will be provided if that is not true.
To the resident: be direct and policy-based. "I cannot accept a phone instruction to make her comfort measures only. Unit policy requires a written order and a second clinician review because there is no advance directive. Please either give me a formal order now with the required review, or I will escalate to the attending and supervisor while we continue treatment and comfort measures."
Documentation should be factual and time-stamped: the patient's condition and vital signs; the daughter's exact request; the resident's exact words; the policy cited; calls made and responses; interventions given; and that no DNR order was in effect. Avoid judgmental labels such as "difficult family" or "resident refused." Record that clarification and escalation are pending.
3. The resident insists you write "comfort measures only" in the chart and says he will sign later. How would you escalate, and what safeguards would you use?
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I would not write an order I am not authorized to write. I would tell the resident that nursing documentation cannot substitute for a physician order and that "sign later" does not meet policy. I would then escalate in a defined chain: attending physician, on-call attending, nursing supervisor, and administrator on call or risk management. If the resident continues to insist, I would ask the supervisor to intervene directly and document the request and my refusal.
Safeguards:
- Continue comfort-focused interventions that are already ordered or that can be obtained from the covering clinician.
- Keep CPR status unchanged until a valid order exists.
- Ask for a second clinician review as policy requires, and document who participated.
- Use a read-back for any telephone order that is legitimately accepted, and repeat it back exactly.
- Notify the daughter that the team is clarifying the plan and that no final decision has been made without proper review.
Reasoning: the nurse's obligation is to protect the patient from both undertreatment and unauthorized limitation of life-sustaining treatment. Escalation is not insubordination; it is the mechanism policy provides when a clinician asks a nurse to act outside scope.