An open letter to those who work with the Texas OOHDNR

My fellow healthcare workers:

We can do a better job managing out of hospital do not resuscitate orders.

I know we can, because we’re more competent than our handling of DNRs has been. DNRs are not rocket surgery. The instructions on the back are wordy, and the form requires several signatures, but it only takes a couple minutes to learn how to do it right. And then it’s easy. Getting it right takes less brain power than a 6th-grade long division quiz.

But the DNRs that we have completing do not reflect our competence as smart, educated and experienced professionals. We are relied upon to be reliable and detailed oriented, but we’re routinely failing to get all the necessary signatures when helping patients or their family members put DNRs in place.

The cost of missing signatures

Tonight at 11:00 pm I had to call the daughter of a newly admitted patient so we could redo a DNR that was filled out by hospital staff during the patient’s most recent ER visit. We had to redo it because it was missing the second signatures of each of the witnesses. This required us to think out of the box about who could be available so late at night to serve as witnesses. I almost suggested we meet at a gas station near her house so that we could ask the clerk or a couple customers to witness. She was able to find a couple neighbors who were awake and willing to help.

Missing witness signatures are the most common error. About once a week I have to approach a family about redoing a DNR because someone else failed to have the witnesses put a second signature in the bottom section. The worst I’ve seen was one filled out by hospital staff that had only the patient’s printed name and a doctor’s signature. As in, no one even signed to declare the desire to forego resuscitation. And someone at a hospital thought that was ok.

Seriously? We’re not dumb. So what gives? Do we not care? Do we not think that attention to detail on DNRs matters?

It matters. It matters to me as a social worker. I don’t want a patient to be denied the right to die naturally because an EMT is concerned a DNR is not valid.

It matters to our organizations. I’ve worked for a dozen hospice directors of nursing, and I’ve never known any to say, “That’s too fine a point to bother the family over.” Nope. The stakes are too high. It matters to nursing homes: They don’t want to have to perform CPR on hospice patients.

The consequences of incorrectly executed DNRs

Invalid DNRs put the patient’s self-determination at risk when they’re not caught and corrected. When they are caught, often the correction process is stressful to patients or family members. The CPR/DNR discussion is uncomfortable for many of clients. Correcting invalid DNRs forces them to have it a second time. Sometimes there’s disbelief and an assertion that they know it’s correct because it was filled out at the hospital. Sometimes there’s profound disappointment in the hospice team for not confirming sooner that the DNR they have is good. Sometimes there’s frustration about the inconvenience of having to find witnesses to sign it again. And then there’s the worry about whether we’ll be able to get it completed in time for a patient to be allowed to die naturally.

My request

Let’s fix this, for the benefit of our patients, their families, and the pride we take in doing our jobs well.

If you work with DNRs, become familiar with what’s required. If your job includes helping patients or family members implement DNRs, take the time to make sure all the signatures go in the right place. If your job includes receiving DNRs, like when a patient admits to your service, please perform a diligent quality control so that errors can be corrected as soon as possible. If a patient will need a new DNR, but you aren’t in a position to handle that, alert your social worker quickly and directly.

For a DNR to be valid

Again, all this depends on being familiar with what DNRs need. They need the following:

  1. The name and birthdate of the patient.
  2. The signature of whoever is declaring that resuscitation will not be wanted. This is the patient if she/he is able to sign, or a family member or legal proxy/power of attorney. This person signs twice, including in the section at the bottom.
  3. It needs either a notary or two witnesses. If it’s notarized, the notary signs twice, including in the section at the bottom. If it’s witnessed, each of the two witnesses signs twice, including in the section at the bottom. One of the witnesses can’t be a family member or an employee of a facility that treats the patient or an employee of a doctor who treats the patient.
  4. It needs a doctor’s signature. The doctor will sign twice, including in the section at the bottom.
  5. The bottom section needs to be filled out. Everyone who signs the DNR has their own place to sign, and they also need to sign in the section at the bottom.

Or just remember these 2 points:

  1. Everyone who signs must sign twice.
  2. A valid DNR has either 6 or 8 signatures.

(If it’s notarized, there are only 6. The declarant signs twice; the notary signs twice; and the doctor signs twice. If it’s witnessed, then there are 8 signatures: The declarant signs twice; witness #1 signs twice; witness #2 signs twice; and the doctor signs twice.)

We can do this.

Please spread the word. Let this become common household knowledge, not only among geriatric healthcare workers. The older population is growing. The number of people who will be needing to communicate their end-of-life wishes is growing. And everyone will need to participate in those discussions. Everyone will find themselves caring for a terminally ill family member or friend.

Everyone in Texas should know what’s required to execute a Texas OOHDNR. But as healthcare workers, we are undeniably responsible to have–and implement–this knowledge.

Sincerely,

Michael Giles LCSW

Turn the page to

Quiz: hospice philosophy and patient self-determination

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Service recovery vs. obfuscation in hospice

5 comments

  1. Well no wonder when patients travel to Texas they gave to get a new DNR. In Kansas for an out of hospital DNR the patient or proxy signs, one witness, and then the doctor reviews the record and signs.

  2. Question related to…….”One of the witnesses can’t be a family member or an employee of a facility that treats the patient or an employee of a doctor who treats the patient.”

    So even a social worker shouldn’t be a witness? As social workers we are not ‘clinically treating’ the pt, nor would we be the one performing CPR. I guess there are 2 ways to understand that. “An employee, of a facility, that treats the pt” OR An employee of a facility that treats pt”. The latter would mean even kitchen or activities, housekeeping or maintenance staff could not witness…..right? The really small print on the back of the DNR says that the employee can’t be a witness “if the employee is providing direct pt care”. Isn’t direct pt care feeding, toileting, dressing, transferring, etc? I’ve worked as a social worker in 2 different SN facilities in TX that were ok with me (but not nursing staff or business office staff or administrator) being a witness.

    1. I think one can be a witness. One has to be neither a relative not an employee. The instructions on the back are a mouthful, but explain it.

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