DNR: An order ignored

Deconstruct a poorly handled situation to help prevent a similar occurrence.


Mr. and Mrs. Smith were a sweet, close couple—high school sweethearts with a solid marriage and a happy family. Shortly after Mr. Smith's 50th birthday, a cardiologist diagnosed him with a congenital heart defect that required a heart transplant. Happily, Mr. Smith tolerated the procedure, and lived the next 20 years without incident.

At his son's wedding, however, the 70-year-old Mr. Smith suddenly began experiencing crippling chest pain. After several tests, the cardiologist told the couple that Mr. Smith's transplanted heart was failing. He was living on borrowed time; his cardiologist told him to get his life affairs in order.

The couple discussed the news at length, and Mr. Smith decided that if the chest pains returned, he did not want extraordinary measures. He contacted his cardiologist and told him he wanted to die peacefully “without any tubes and pipes” coming out of him. The cardiologist entered a DNR order in Mr. Smith's chart.

Shortly thereafter, Mr. Smith had chest pains again. He was taken to the hospital and admitted directly to the ICU. Upon admission, the Smiths clearly explained the husband's wishes about his end-of-life care.

Dr. Jones, the hospitalist managing Mr. Smith's case in the ICU, was impressed by the closeness of the couple's relationship, and how supportive Mrs. Smith was of her husband's decision. Dr. Jones discussed the case with the patient's private cardiologist, who confirmed that the decision was reached after lengthy reflection and discussion. Dr. Jones summarized his patient's plan of care in Mr. Smith's electronic medical record (EMR) and entered the DNR order.

Later that night, Mr. Smith became agitated and complained of pain in his lower abdomen. An ICU nurse sought approval from a covering hospitalist, Dr. Williams, to administer a narcotic to ease the pain. Dr. Williams gave approval over the phone. After about 3 hours or so, Mr. Smith's agitation returned and the nurse paged Dr. Williams again, who then prescribed another narcotic over the phone.

An hour after prescribing the second narcotic, the nurse called to tell Dr. Williams that Mr. Smith's breathing had become labored. Dr. Williams came to Mr. Smith's room and told the nurse to page the anesthesiologist on call for an intubation. The anesthesiologist told Dr. Williams he would not intubate, because he had read Mr. Smith's medical record and seen a DNR order.

Dr. Williams became visibly frustrated and firmly informed the ICU nurses that he would intubate Mr. Smith himself. The ICU nurse in charge told Dr. Smith that his actions would directly oppose Mr. Smith's expressed end-of-life plan and contravene the DNR order. Dr. Williams moved ahead with the intubation, telling Mrs. Smith in a brief conversation that the intubation would “give her husband a chance at living.”

While the intubation occurred, Mrs. Smith was visibly upset, calling her husband's name repeatedly and telling him not to worry. She was also shouting at Dr. Williams that her husband didn't want any tubes in him.

The following morning, Dr. Jones arrived and learned about the situation from Mrs. Smith, who asked him if she had done something wrong. He immediately extubated Mr. Smith, who passed away comfortably holding his wife's hand.

When pressed by the daytime physicians in morning report as to why he intervened against a patient's clearly stated wishes against intubation, Dr. Williams was unable to give a clear reason. No disciplinary action was taken against him, and the patient's family didn't pursue legal action. Dr. Williams continued to practice at the hospital.

When hearing a story like this, it's tempting to write off the villain—Dr. Williams—and feel a little better about how you would never do such a thing. However, it's worth examining, objectively and without a sense of blame, what those involved in the situation could have done differently to achieve a better outcome.

Here are my ideas:

  • The daytime hospitalist, Dr. Jones, could have spoken directly to the covering hospitalist, Dr. Williams, and informed him of the patient's end-of-life plans. Typically, Dr. Jones did this; however, he knew from past experience that Dr. Williams had little patience for detailed conversations at signout, often cutting them short and saying he'd “just read the chart.” While it may have been difficult, Dr. Jones could have persisted in ensuring Dr. Williams listened to his full sign-out.
  • The ICU nurses could have engaged senior nursing leadership to stop Dr. Williams from intubating Dr. Smith. ICU nurses should have names and numbers of people in their chain of command at the ready, especially at night. Unfortunately, many of the nurses at this hospital do not feel empowered to challenge a physician, a systemic problem that needs to be addressed.
  • No one from the hospital administration called Mrs. Smith to explain what happened. This is especially important since she expressed feelings of guilt that she may have “done something wrong” to cause her husband's wishes to be ignored. Also, Dr. Williams should have been held accountable in some way for his actions.