T he estate of Rodney Knoepfle successfully sued a hospital for not honoring his wish to be treated as “Do Not Resuscitate/Do Not Intubate” [DNR/DNI] during a 2016 hospitalization. A recent Boston Globe article said Mr. Knoepfle, who was 67 at the time, had a history of congestive heart failure, chronic atrial fibrillation, coronary artery bypass, aortic valve replacement, stroke, osteomyelitis and three operations on the right hip, cervical and lumbar fusion surgery, and chronic pain.

The Globe piece said he was admitted to a hospital for an unspecified “common procedure.” The Plaintiff’s Trial Brief says that on the date of admission, a physician placed an order in the chart confirming his resuscitation status of DNR/DNI. “A blue dot was to be affixed to Rodney’s physical chart to signify his ‘no code’ status. Finally, Rodney was to be fitted with a blue armband indicating to all providers his DNR/ DNI status.” He was admitted to a regular floor.

On his third hospital day, telemetry staff notified his floor nurse that he was in asystole. After unsuccessful attempts to summon help, she pushed the code blue button in his room, and the code team arrived. The brief said there was confusion regarding his code status. CPR was initiated. He was given epinephrine. A nurse called Mrs. Knoepfle, who confirmed his DNR/ DNI status. The resuscitation was stopped, but Rodney had regained a pulse and was breathing on his own. He was transferred to the ICU.

The next day, he became unresponsive due to a bradycardic arrest. He was ventilated with a facemask and given drugs to increase his heart rate. After recovering, he agreed to have a pacemaker placed and was transferred to a rehab facility with “massive bruises [on] both upper arms and chest from compression.” He never regained his pre-resuscitation state of health and required fulltime oxygen supplementation and assistance with ADLs until he died 2 years later.

According to the Globe, “the hospital acknowledged the mistake and claimed that reviving Rodney was an oversight by staff caught up in the moment.” An Associated Press story about the 2019 trial said the jury found the hospital and one of its physicians negligent for violating Rodney Knoepfle’s patient rights and awarded $209,000 in damages for medical costs and $200,000 for mental and physical pain and suffering.

How can wrongful resuscitation be prevented? A survey of hospital nurse executives published in 2007 in the Journal of Hospital Medicine found that 72% of DNR orders were located in paper or electronic charts only and that 25% of hospitals added one of eight color-coded wristband to supplement the order. More than 70% of those who responded said confusion about DNR status had caused problems with patient care. The authors called for standardization of DNR orders and wristband colors. I conducted a Twitter poll on this topic in December 2020. Of 162 respondents, 67.3% said DNR orders were on the patient chart only, suggesting that little has changed during the past 13 years.