Written by Physician’s Weekly Blogger, Skeptical Scalpel

 

The estate of Rodney Knoepfle successfully sued a Montana 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 described some of the circumstances of the case.

Mr. Knoepfle, who was 67 years old at the time, had a past medical history that included 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 circumstances surrounding his resuscitation were better explained in the Plaintiff’s Trial Brief.

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. She found him in the restroom propped against a wall and unresponsive. She tried to summon help, but after pulling the emergency cord in the bathroom, nobody came. She attempted to use the Vocera mobile dispatch system, but it wasn’t working properly. 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. By this time, 10 minutes had elapsed. The resuscitation was stopped, but Rodney had regained a pulse and was breathing on his own. He was transferred to the ICU.

On the following 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 both upper arms and chest from compression.” He never regained his pre-resuscitation state of health and required full-time oxygen supplementation and assistance with activities of daily living until he died 2 years later. The lawsuit was filed before his death.

According to the Globe, “the hospital acknowledged the mistake and claimed that reviving Rodney was just 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.

The Globe said the case “appears to have been the first jury verdict for the plaintiff in a wrongful prolongation of life suit in the United States, according to several legal experts.”

How can wrongful resuscitation be prevented? A 2007 paper in the Journal of Hospital Medicine reported the results of the survey of hospital nurse executives. The study found that 72% of DNR orders were located in paper or electronic charts only and, 25% of hospitals added a color-coded wristband to supplement the order. Eight different colors were used. Over 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.

Anyone who has worked with electronic medical records can verify that logging into a computer and looking up a patient’s DNR status would waste valuable time.

I conducted a Twitter poll on this topic last week. Of 162 respondents, 67.3% said DNR orders were on the patient chart only. This suggests that little has changed over the past 13 years.

 

Skeptical Scalpel is a retired surgeon and was a surgical department chair and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last 9 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 3,700,000 page views, and he has over 21,000 followers on Twitter.