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Based on a review of two open and eight closed medical records, it was determined that the hospital failed to comply with Patient #1's (P1's) recently documented end of life wishes for Do Not Intubate/No CPR (cardiopulmonary resuscitation) when the hospital intubated P1.

Patient #1 (P1) was an elder patient who presented to the emergency department with generalized weakness. P1 had multiple potentially life-threatening comorbidities. P1 had no Advanced Directive. However, during a recent admission to the hospital, in which P1 was discharged 7 days prior, P1's code status revealed P1's choice for Medical Orders for Life Sustaining Treatment (MOLST) of Do Not Intubate (DNI)/No CPR (cardiopulmonary resuscitation), also categorized as MOLST A-2. The MOLST orders were considered a durable order which, unless changed by P1, would follow P1 through all subsequent medical care. Further, the hospital had a "Code Status History" which could be accessed upon subsequent presentations for care.

During P1's most current presentation it was noted by a physician in the History and Physical that, "He is unable to provide any history. The daughter says states (sic) that the patient is more confused than is typical for him." A Review of Systems (ROS) was documented as, "Unable to obtain due to altered mental status and dementia," and, "Neurology: AAOX2 (alert and oriented x 2), patient is unable to cooperate with exam due to altered mental status; Psych: Unable to assess due to history of dementia and mild altered mental status." This meant that P1 could not have expressed a credible change in P1's desire for DNI/No CPR.

Review of P1's medical record "Code Status History" revealed all prior code statuses with the date and the physician who wrote the code orders including the DNI/No CPR one week prior to the current presentation. It was not determined if the physician actually viewed P1's previous code statuse documentation in P1's record, but the physician wrote an order for "Full Code" within 4 hours of presentation to the emergency department. P1 was subsequently transferred to a medical unit.

Some hours later, P1 went into respiratory distress. A Rapid Response was called at 0331. Review of the Rapid Response form revealed a place to document P1's code status, though no code status was documented. P1 was intubated at or about 0420. An order for the intubation was not written until 0659 as "Code Status: Intubate, No CPR (MOLST A-1)." That meant that P1, who had previously expressed a desire for DNI/No CPR, was intubated against P1's expressed wishes.

In summary, while the hospital had a way to view the code status of patients, this process failed to appreciate P1's wishes for DNI/No CPR.