Mr. Jones is a 92 year old gentleman with acute congestive heart failure. He has a long list of comorbidities, and his prognosis is guarded. Upon discussion with Mr. Jones’ family members present, the medical resident documents a “do not resuscitate decision” in the electronic record on day one of hospitalization. On day three of hospitalization, Mr. Jones’ daughter, named as agent in Mr. Jones’ durable medical power of attorney, arrives from out of town and speaks to the attending physician, asking him to cancel the DNR order and resuscitate, if necessary.

This is handwritten in the progress notes, which are scanned into the electronic record, but the electronic field where DNR orders are documented is not changed. In addition, in the daily progress notes entered by the medical resident, the day one discussion resulting in the DNR order continues to be copied and pasted into the record each day, making it appear that the DNR order is still in force.

Mr. Jones’ son disagrees with the daughter’s decision and feels it was uninformed; he complains that he (as a registered nurse) was in a better position to make the correct decision. Unfortunately, on day 5 of hospitalization, Mr. Jones’ condition deteriorates and he has a cardiac arrest. “Code Blue” is called by the nurse on duty, and the team arrives to begin resuscitation. Shortly after they begin, the unit clerk enters the room and tells the team that “this patient is DNR.” Resuscitation is canceled and Mr. Jones dies.

1. Who had authority to decide whether Mr. Jones should be resuscitated? Is any information that is necessary to answer this question missing from the scenario? If so, what else must be known to answer this question.
2. Who should be responsible for documenting DNR decisions?
3. What should happen if a record reflects conflicting documentation?
4. Are there circumstances in which family members should NOT be allowed to make DNR decisions on behalf of a patient?
5. How did the format and capabilities of the electronic record contribute to the confusion in this case? What could be done to address those problems?

Each of these questions should be answered should be at least a paragraph.