Blue about Code Blue

[barbaralynn]

I am a new nurse working on the Oncology floor. The stages of cancer we treat vary from newly diagnosed to metastatic. Some of my patients have good prognoses while others have only weeks or possibly days to live. Recently I experienced my first Code Blue. The patient, in his mid-eighties, had been in an altered state for 2 weeks or so: disoriented, incoherent, and inclined to curse at nurses over and over. Although he was not my patient, hearing his unmistakable behavior from the teaming station and hallway, I sensed a detachment from reality. One day, while charting, we suddenly heard a soft and anxious voice of a family member coming from the patient's room, pleading for help. The experienced nurses around me jumped to their feet and into action while I followed, my heart beginning to race. A few minutes later several professionals had crowded into the room. I tired to participate and be helpful but seeing the patient's open and lifeless eyes, feared he was unlikely to make it. Indeed, after an honest attempt the code was called and time of death noted.

Several feelings and thoughts have gone through me since witnessing and my first Code Blue, however there is one thought I am grappling with and want to share with you:

This patient had lived a long life, and being terminally ill was going to die soon. Yet he was not DNR. Because of this, the natural last breaths of his life and still moments afterward were replaced with a violent (for lack of a better word) physical act. His wife trembled as my clinical manager led her away from the scene. I thought about when my parents will die and know neither they nor I will want this if, one day, found in a similar situation. I thought about how important it can be to chose DNR. I realize however it is not for everyone and each situation is personal, individual and even complicated.

For you nurses who have witnessed many codes, how often have you seen a similar circumstance as the one I've described? More importantly, is DNR discussed and rediscussed with patients as they progress in their illnesses and into older age? Are issues such as likeliness of being revived, invasiveness of the code itself, and its effect on family members (witnessing the code or being whisked away from their loved one) discussed openly and honestly with the patient and family, so that they may make an informed decision? Anyone's feelings and opinions on this sensitive topic is welcome and appreciated. I am also curious about the thoughts of more experienced nurses.

Thank you!!!!

[Mulan]

This is a death defying society.

Everyone is supposed to live forever and be in perfect health.

[pookyp, LPN]

This is a death defying society.

Everyone is supposed to live forever and be in perfect health.

This is what my teacher says.

[Susie2310]

One of my nursing instructors says it really depends on how you ask the patient... "Do you want to be resuscitated?" vs "Do you want to be allowed a natural death?" She stressed that CPR was meant for the 'healthy-dead' and wasn't intended to be used on the old, frail, and very sick.

I'm a new grad and just experienced my first code last week so I've been reviewing my notes from school on this topic. The patient was revived. I didn't know him at all though. When I arrived all of the major tasks were already being performed but no one was recording, so I took that on. I did a pretty good job and the nursing supervisor used my notes to fill out the report.

I disagree with your nursing instructor's question to the patient "Do you want to be resuscitated," versus "Do you want to be allowed a natural death?" I am going by your literal wording of your instructor's comments in my response here. Does your instructor explain the difference to the patient? As a nurse I understand the question. If you asked my family members I believe they would be confused. The question is not straightforward. People have a right to choose to receive CPR/ACLS if they wish, regardless of their age or medical condition. Your instructor has the right to his/her belief that CPR is meant for the 'healthy-dead' and wasn't intended to be used on the old, frail and very sick, but he/she does not have the right to impose his/her beliefs on other people (patients and family), who may have different values and beliefs, and who have a right to make their own choice.

I am beginning to feel some people (people in general, not your instructor in particular) are seeing the old, whether sick or healthy, who choose life-sustaining measures, as a burden, and are subtly indicating to them that they should not choose life-sustaining measures. I find this reprehensible. Provide sufficient information regarding the choices available, respect the patient/family's choice, and carry out their wishes.

[PMFB-RN, RN]

As a full time rapid response RN I go to many codes, occasionaly am the one running tthe code. Your experince is typical. They are frusterating in the extream, rarely helpful, usually brutual and crule. Our society simply does not handel end of life isses very well. Add to that cowardly physicians and other staff who don't have the guts to be strait up and honest with the family and patient.

It is VERY rare to have a sucessful code, meaning a patient leavers the hospital to have some semblance of a qualiety life. Occasionaly we get a cardiac arrest code on a young patient (

[chrisrn24]

My mother thought that DNR meant the person wouldn't be treated.

There needs to be more education about what DNR means so people can make informed choices.

[PMFB-RN, RN]

My mother thought that DNR meant the person wouldn't be treated.

There needs to be more education about what DNR means so people can make informed choices.

*** Right. I often describe it to patients as "What do you want us to do after you die?" to make clear that care won't change while they are alive.

[dandk1997RN, MSN, RN]

My mother thought that DNR meant the person wouldn't be treated.

There needs to be more education about what DNR means so people can make informed choices.

Agreed. People just don't understand. I wish people would think about these things before they're in the hospital and scared. I asked an OLD 66 yr old (multiple cancers, bypasses, still smoking, falls, social issues, etc) woman if she had a health care proxy and explained it to her. She told me no but her boys know what she wants. I tried to explain that we need a name in writing and offer to get her the form, explaining the whole thing and that it is simple...and she refused. So she essentially told me her sons should be her hcps, but her lack of understanding (and refusal to be truly educated) is going to lead to us following our protocols because we've got nothing on paper. :-(. And this was just for HCP info- cant imagine trying to bring up MOLST.

[jadelpn, LPN, EMT-B]

There does need to be much more education on what DNR means. What comfort care is. However, we are often not party to private conversations in families. Some patients are really clear on their desire to "have everything done". And although we may not agree, it is an absolute right.

This is why it is so important to have these conversations with one's health care advocate/proxy. Someone who will be one's voice. Who will in fact do what you want, as opposed to what they or even any of us want.

It is complicated, personal, and needs frank education most importantly at the begining of a terminal diagnosis. (and in fact when one fills out a health care proxy).

Should be mandatory education for patients.

[Good Morning, Gil]

In short OP, too often. That is hands down, the hardest part of my job in ICU (and will be for you in oncology, too). We educate, and educate some more, but at the end of the day, a 90 year old person on 3 pressors, septic shock d/t PNA secondary to stage IV lung, breast, prostrate (any cancer) is a full code if a POA deems they're a full code (a hypothetical here, not an actual patient). Just the way it is. So we continue with care, inserting lines, frequent labs, abx, etc.

How I keep it in perspective? That patient in that bed still needs good care, and I'm there to provide it (as are the other nurses on the unit). Also, I make sure the physician schedules a family meeting and/or palliative consult to ensure the family understands what is happening. (Sometimes this leads to at least a DNR status, and sometimes terminal wean, comfort care; patient advocacy is so important). Is it easy? No, but I know I have done everything for that patient/family, so I feel good about my work at the end of the day. Eventually, the person will tire, and die (like what happened in your code). That code was a blessing (otherwise, patient could have lived longer, delirious, possibly sent to ICU, and having to be intubated, lines placed, pressors started, etc), prolonging life further.

[anotherone, BSN, RN]

Have had some pts who in their history prior to being my ot have been coded and are still walkie talkies. All under 40 with a VERY short down time.

Will there come a time here where payment dictates what is done?

[Esme12, ASN, BSN, RN]

I agree that codes are violent acts. There is nothing to describe the brutality that occurs to the untrained, or trained, observer. I don't think people really understand what. DNR really means and if they do they don't really understand what a code means....the brutality of defibrillation and CPR...that distinct sound of cracking ribs... the trauma of intubation...that death bears little resemblance to what we see on TV

I think that many people are ambiguous about their own feelings about death. They are uncomfortable talking about it and this includes physicians who's first oath is "Do no harm". Once as I was participating in the care of a patient with an inoperable brain tumor who came to my ICU in Status Epileptics....I heard the oncologist repeat over and over that the 48 yo patient , who had a limited DNR (no defib no CPR), was seizing due to hypoxia and needed to be intubated. Proclaimed success when the chemically paralyzed patient stop visually seizing....and she informed the family that they had been stabilized.

To me that MD needs to be taken aside and given the what for....to me that is giving false hope and is cruel and unusual punishment. No wonder they were hysterical and devastated when this patient died hours later when they herniated their brainstem.....while the oncologist was at home snug in their bed, leaving it up to the ICU nurses to help this family find some peace.

I know there are worse things than death. I have seen them and cared for them. Sometimes I think people either love someone too much to let them go...or they are paying them back somehow for bad deeds. I believe in putting my pets down as an act of humanity because I love them enough to let them go. But the patients decision has nothing what so ever to do with what I want and what I believe. The facility where I had worked allowed the ICU nurses to talk with the families about DNR. They trusted us to have these discussions and then would come in to "really talk" to the families and write the orders. We talked about DNR and that it is not a do not treat.

I think using terminology like "using a machine" to "help them breathe".....are using euphemisms for the real thing. How many times have heard a family flip out when they found out their loved one is on "life support" because no one told them!!! so you tell them what did they think the tube was...they state..the doctor told me it was "a temporary tube to help them breathe"....that their loved one "never wanted to be on life support".

I think we need to recognize that sometimes medicine isn't perfect. I think we need to remember that in being human we are flawed. I think we need to remember it is not about how we feel the patients but that is it all about how the patient/family feels and respecting their wishes and decisions. To take these moments to learn and have these discussion with ourselves about how we feel and what would our decision would be for our family.

Even After all my years being a nurse....for the only job I really ever had was being a nurse...I became a nurse when I was 18 years old.....I still had complete faith that my father would peacefully die in his sleep at home in his bed at 80 years old......not surrounded by machinery after coding in the middle of the night....even I had trouble removing my best friend from life support knowing full well he would never get better and never come home.

It is ok to be conflicted....it's good to question....but when dealing with humanity remember it is messy and nothing is ever crystal clear. I am not saying codes get easier but they do become less traumatizing with experience. Take comfort that you are there to care for that patient in the best way you humanly can but that you are limited i the decision process. ((HUGS))

[dudette10, MSN, RN]

There is a flip side to this. I get a little uncomfortable during my admission questions when a young, relatively healthy patient talks about not wanting to be on life support. I keep thinking,"Yes, you do, because you have a chance to make it back!" I explain that sometimes life support truly is temporary to allow the body to heal, and that the pt will have a chance to talk about it further when the residents come in for the H&P. what it comes down to is that the decision is not black or white. It should be based on the pt's chance of some sort of quality of life, however the patient defines that.