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Difficulty: Very hardClient Rights and Advocacy

A practical nurse (PN) is caring for a client with end-stage heart failure who has a signed Do Not Resuscitate (DNR) order on file. The client suddenly develops acute, severe chest pain and extreme dyspnea. The client grasps the PN's arm and gasps, 'Please do whatever it takes to save me! I changed my mind!' The client's designated healthcare proxy is at the bedside and states, 'No, they are just panicking. Do not intervene; the DNR must be followed.' Arrange the following actions the PN should take in the correct order of priority.

  1. 1Activate the facility's rapid response or emergency medical system.
  2. 2Initiate immediate stabilizing measures, including supplemental oxygen administration.
  3. 3State clearly to the healthcare proxy that a competent client's verbal request overrides a written advance directive.
  4. 4Communicate the client's change in condition and DNR revocation to the attending healthcare provider.
  5. 5Document the client's exact statements, the proxy's objections, and the provided care in the electronic health record.

Answer

The correct chronological sequence prioritizes life-saving interventions first, followed by advocacy, communication, and documentation: 1) Activate emergency response, 2) Initiate stabilizing measures, 3) Inform the proxy of the client's rights, 4) Notify the provider, and 5) Document the event.
The correct sequence flawlessly integrates the nursing process, emergency prioritization (Maslow's ABCs), and client advocacy. Because a competent client's verbal revocation legally overrides a written DNR and a proxy's demands, the nurse must first treat the situation as an acute medical emergency by calling for help (Step 1) and providing immediate scope-appropriate stabilization (Step 2). Once physiological safety is addressed, the nurse must advocate against the proxy's interference (Step 3), notify the provider to update the formal medical orders (Step 4), and finally complete the legal documentation (Step 5).

Step-by-Step Solution

1
Activate the rapid response or emergency system.
Summons immediate advanced medical assistance to the bedside.
The client has verbally revoked their DNR and is experiencing an acute cardiopulmonary emergency. Prioritization always begins with immediate life threats (ABCs).
2
Initiate immediate stabilizing measures.
Addresses the physiological crisis while waiting for the emergency team.
The PN must provide immediate, scope-appropriate basic life support (e.g., oxygen, head elevation) to sustain the client's airway and breathing.
3
Inform the healthcare proxy of the client's right to revoke the DNR.
Prevents the proxy from obstructing emergency care.
A competent client retains the right to revoke an advance directive at any time. The PN must advocate by clarifying that this direct request legally overrides both the written document and the proxy's demands.
4
Notify the attending healthcare provider.
Ensures medical orders are officially updated.
The chain of command must be followed to legally cancel the DNR order in the system, but this is secondary to stabilizing the client.
5
Document the incident in the electronic health record.
Creates a permanent legal and clinical record.
Accurate documentation of the client's exact words, the proxy's statements, and the care provided is legally essential but must occur only after the client's immediate safety is secured.

Key Concept

A competent client can legally revoke an advance directive (such as a DNR) at any time, including verbally during an emergency. This revocation immediately supersedes the written document and the authority of any healthcare proxy. Nursing interventions must prioritize physiological needs (ABCs) before administrative tasks.
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Client Rights and Advocacy

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