HospitalInspections.org

Based on interview and record review the hospital failed to protect and promote each individual patient's rights.

Findings:

1). Based on interview and record review, the hospital failed to ensure that the patient's and family's rights and request related to the end-of-life plan of care were followed resulting in the patient's death without emergency interventions. Cross refer A0129.



The cumulative effects of these systemic problems resulted in the hospital's inability to effectively ensure compliance with the statutorily mandated Condition of Participation for Patient Rights.

Based on interview and record review, the hospital failed to ensure that the patient's and family's rights and request related to the end-of-life plan of care were followed resulting in the patient's death without emergency interventions.

Findings included:

Review of the medical record revealed that Patient 35 was a 59 year-old that was admitted to the hospital Emergency Department (ED) on 9/8/2020 at 1:38 a.m. with a diagnosis that included COVID-19. The patient also had other pre-existing medical conditions including hyperlipidemia (elevated cholesterol). The patient presented to the hospital's Emergency Department (ED) with a cough and shortness of breath. During the patient's stay in the ED, multiple medical diagnostic tests and studies performed. The patient's medical condition then began to decline, and required supplemental oxygen. The patient was ultimately intubated with a breathing tube and placed on a ventilator.

Later in the ED on 9/8/2021 at approximately 7:30 a.m., the patient experienced a cardiac arrest (no detectable heartbeat). The patient was 'coded' successfully (emergent attempt by medical team to revive the patient), and remained intubated in the ED. The patient again experienced an episode of cardiac arrest later the same day at approximately 11:25 a.m., and was successfully 'coded' a second time. The patient was admitted to the hospital but remained in the ED because the inpatients beds were full.

The Physician Notes documented by the consulting physician (Medical Staff 27) dated 9/8/2020 at approximately 6:30 p.m. contained an entry that read, "(Medical Staff 26) discussed current deterioration in (patient's) clinical status. Unfortunately given maximum support with 3 pressors (medications) and high peep flo O2 (oxygen), 2 doctor documentation for futility of care if in the event patient has a 3rd cardiac arrest."

The Physician Notes documented by the attending physician (Medical Staff 26) dated 9/9/2020 at approximately 10:20 p.m. contained an entry that read, "I discussed deterioration in (patient's) clinical status with (consulting Medical Staff 27) and also with patient's family by phone on September 8. DNR (Do Not Resuscitate) declared per 2 physician consent with in order to avoid 3rd CPR (Cardio-Pulmonary Resuscitation) when the prognosis is dismal. Unfortunately given maximum support with 3 pressors (medications) and high peep flo O2 (oxygen), 2 doctor documentation for futility of care if in the event patient has a 3rd cardiac arrest."

Review of the patient's admission packet indicated that he did not have an Advance Directive, but was provided information related to right to make decisions about medical treatment.

There was "DNR Progress Note" in the medical record of the patient. The front-side of the document read, "Rationale for order(s) to withhold or withdraw life-sustaining treatment: Qualitative futility: Life sustaining treatment sustains a quality of life that falls well below a threshold considered minimal by general professional judgement." Further, a handwritten notation also read just below, "Overwhelming evidence of multi-organ failure with 100% mortality risk, S/P (status post, 'following') CPR x 2 (two attempts of CPR). The document was signed by Medical Staff 26 at 12:22pm on 9/8/2020 and by Medical Staff 27 at 12:22 p.m.. The back-side of the document contained the heading of 'Description of Discussion Regarding Withholding And/or Withdrawal of Life Sustaining Treatment or Procedures" with the following below:
"Diagnosis - Acute hypoxemic respiratory failure due to COVID-19 pneumonia, acute MI (myocardial infarction, 'heart attack'), cardiogenic shock, renal failure, shock liver"
"Prognosis - Dismal"
"Assessment of patient's decision making capacity - N/A (not applicable)"
"Degree of influence by psychiatric problems - N/A"
"Treatment options discussed with patient (including medical consequences - N/A"
"Who participated in discussion - (Physician 26 and 27)"
"Patient's or surrogate's preferences and decisions - N/A - see reverse (front side of document)"

Medical Staff 26 was interviewed on 5/28/2021 at approximately 9:50 a.m.. The physician stated that Medical Staff 27 discussed that the patient be made a DNR because of the patient's poor condition. "(Medical Staff 27) and I talked about the patient, and the fact that he had already been coded twice and his organs were failing. I called and spoke with the family but they told me they did not want to hear anything negative or bad, and to stop talking." Medical Staff 26 added, "(Medical Staff 27) mentioned the option of a 2-physician DNR that she had seen at other hospitals. I didn't know if this hospital had a similar policy, but it was my decision to go ahead with it."

Medical Staff 27 was interviewed on 5/27/2021 at approximately 4:10 p.m. The physician recalled the condition of the patient, "(Patient 35) was deteriorating and had already coded twice. Death was imminent. I spoke with (Medical Staff 27) about the situation because this was what we did at other hospitals I have been at. If the patient was in this type of situation, we did the 2 physician DNR" The physician added, "The Ethics Committee didn't meet until after the death of the patient. We talked about the scenario. We didn't have a policy addressing this situation, so we decided that a draft amended policy would be created. I think it is still being reviewed by our Attorney General."

Review of the minutes from the 10/15/2020 Ethics Committee Meeting revealed discussion of the events surrounding and leading up to the death of Patient XX. According to the minutes, there were notations that read "Patient's (care) preference: Unknown, patient is incapacitated at this time. No living will. Family's preference: Full Code (attempt to provide life-sustaining treatment if patient has cardiac arrest and/or is non-breathing). Refused to hear/acknowledge severity of situation. Issue: Was the two physician DNR appropriate despite the patient's family being available." The document also contained documentation:
* "Agreement: Members (of the Committee) were in general agreement that the care of the patient was appropriate given the clinical situation of imminent death ..."
* "There were attempts to notify the patient's family and have discussions regarding goals of care. The family did not receive a full explanation regarding the patient's condition and care, but the family was refusing to participate in those discussions.
* "Patient's wife did not know about the DNR until the nurse called (after death of patient) regarding the patient's belongings."
* "The two physician DNR (process) is not supported by hospital policy."
* "The policy also does not include a mechanism for conflict resolution when the family does not participate. The policy states: In situations where the patient or the surrogate decision maker disagrees with the attending physician regarding the decision for a DNR order, the physician must honor the wishes of the patient or surrogate decision maker and may choose to make arrangements to transfer patient care to another physician, resolve the conflict through multidisciplinary family/patient conference, or refer issue to the Ethics Committee."

Medical Staff 28, a member of the Ethics Committee, was interviewed on 5/27/2021 at approximately 4:30 p.m. The physician stated they did not attend the 10/15/2020 Ethics Committee meeting, but was aware of the situation that had transpired. The Physician was asked if the situation that took place regarding the 2-physician DNR that took place was consistent with hospital policy, and the Physician responded the policy was not followed. "The Ethics Committee could have possibly convened before the patient expired to review the situation and all the associated factors related to the patient's condition and family, but they did meet afterwards." She added, "The process perhaps wasn't followed."

Review of the hospital's policy titled, "DNR Orders" (Policy A-R1500, effective 11/11/2013) reads in Section 4, Number 1: "In situations where the patient or the surrogate decision maker disagrees with the attending physician regarding the decision for a DNR order, the physician must honor the wishes of the patient or surrogate decision maker and may choose to make arrangements to transfer patient care to another physician, resolve the conflict through multidisciplinary family/patient conference, or refer issue to the Ethics Committee ..."

Review of the hospital's policy titled, "Patient Self-Determination (Advance Directives)" (Pollicy A-R1400, effective 2/182020) reads in Section G (page 1): "In those cases where an incompetent adult is without an Advance Directive, decisions regarding acceptance or refusal of medical treatment will be made by the following legal representative, if reasonably available, in order of priority: 1. Spouse of the patient."

In a document obtained from the hospital dated 10/5/2020 (following the patient's death) there are notes from an interview conducted with Patient 35's spouse. The notations in quotes read, "One of the nurses called me and mentioned the doctor ordered a DNR, what is that DNR ...I didn't agree for my husband to be put on DNR!"

The Nurse Notes on 9/8/2020 at approximately 10:30 p.m. had an entry that read, "2110 (9:10 p.m.): Received call from family. Family wants to rescind DNR (Do Not Resuscitate, no CPR). States they did not agree with the DNR order. DNR order signed by 2 physicians 9/8/2020 at 12:22 p.m."

The Physician Notes documented by Medical Staff 29 dated 9/10/2020 at approximately 8:40 p.m. documented, "Called by RN at 7:43 p.m., (Patient 35) unresponsive and in asystole (no electrical activity in the heart, no heartbeat) on cardiac monitor. On examination, patient non-responsive, brain stem reflexes absent, pulseless, no heart sounds, and no breath sounds. I called family to give them the news of the patient's death. They were understandably very upset. Time of death called at 7:59 p.m. on 9/10/2020." There was no evidence in the medical record that indicated the patient was coded or provided CPR on 9/10/2020.