Blue about Code Blue - page 3

by barbaralynn

7,300 Unique Views | 42 Comments

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... Read More


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    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.
    nrsang97 and Esme12 like this.
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    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?
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    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))
    calivianya, PMFB-RN, anotherone, and 1 other like this.
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    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.
    1feistymama likes this.
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    Because of exactly what you described above, I left ICU nursing and went I to hospice. I can't tell you how many futile codes we ran when the chance for a peaceful end of life was very disturbing to me.

    It is the decision of the patient. It bothers me when the prognosis and options are not described and explained well enough to these terminal patients. They need to be educated. It also bothers me when family keeps them alive for themselves. That's why I am a big advocate of at least an advanced directive. A very well explained advanced directive.
    anotherone and Good Morning, Gil like this.
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    Fortunately I have never had to code an end-of-life oncology patient. What struck me reading this thread is how common people are saying this is... I am a pediatric nurse and have worked oncology in some way or another my entire career. Reading this thread would almost make me think that people are more willing to let their children go than they are to let their elderly parents go. Virtually every oncology death I have experienced was peaceful. The child was either at home with hospice or in the hospital with comfort measures only. The child was usually on morphine and possibly versed or ketamine drips. Their hearts were strong so what typically happened in the end was brainstem herniation, they peacefully stopped breathing and cardiac arrest came seconds later. My very favorite patient died in the ICU on BiPAP- her parents had rescinded her DNR several times and it had finally been reinstated. She had finally gone home with hospice/round the clock nursing. One morning, she desatted and her mother decided it wasn't time and called 911. Once she got to the ICU, the team instructed them to call family in and once everyone arrived, the BiPAP was discontinued and she passed. I saw her only two or three hours before she died and knew that- but for the BiPAP- she was already gone. I have never had a pediatric oncology parent who wanted compressions or defibrillation... even the ones who wanted intubation did not want those things. Even the ones who held out and "wanted everything done" ended up agreeing to the DNR in time.

    In the case of my own parents- my mother and I have discussed this several times. My grandmother (her mother) suffered a devastating stroke at the age of 56. This was in the '70s and I don't think anyone in the family knew what to expect. She had gone to work as if it were any other day, complained of a bad headache to a co-worker and then fainted. Because she was otherwise healthy and relatively young, my grandfather wanted everything done. I don't think they knew at the time what everything entailed- she ended up with a trach (I think she was decannulated eventually because I don't remember her with a trach but I've seen the hospital records so I know she had one for a period of time), a G-tube, a VP Shunt. She never recovered and was in and out of nursing homes for the next 16 years until she finally passed. I was nearly 11 when she died and she never knew who I was. Everyone in my family knows that this is not what they want. When my grandfather died, he was doing what he did every Wednesday night for the majority of his adult life- playing Pitch with his buddies. He got sick, went to the hospital, refused all treatment and died 3 days later.

    This is precisely one of the reasons I couldn't work with adults. I could not fathom doing such horrible things to prevent someone from having a peaceful death.
    anotherone likes this.
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    Death is such a taboo in our society. Nobody wants to talk about it, nobody wants to hear about the possibility of it, everybody believes they are invincible and it will never happen to them. I agree with the poster who said that death is seen as a failure, rather than the natural end of life.

    There have been so many times I have wanted to tell family members (I work in LTC), "It's ok for them to die! It's going to happen anyway, accept it!" Of course I don't say that, but it is frustrating.

    That's my emotional perspective. My intellectual perspective is we have the freedom of choice. If someone chooses full treatment, that's what they deserve to get. You can educate the pt. and family all you want, but if they don't want to hear it, they won't. This is a social problem, requiring an overhaul of collective thinking. Hospice and palliative care are growing specialties. I think we're slowly making progress in that direction.
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    It can be hard, BUT...my job is to follow the wishes of the pt and their family. If they are 98 years old and a full code, by golly, we are going to do it all. Do they have good outcomes? Usually, no, but if that is what they want, that is what I do. I don't love that so many people can't understand that sometimes being a full code is just going to equal suffering and ultimately death, but that is not my choice to make. And I hope, even with my medical training, that I don't ever have to make that choice for someone I love. It's easy to say "make them a DNR" while everything is fine, but I've never had to make that sort of decision for someone I love. I would hope I could make a rational choice, but you never know.
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    Our providers are all really good about discussing DNRs with family members. However, the timing of these discussions is not the best when it happens in the ER, while the family is emotional and stressed about the patient. Unfortunately, many families have given no thoughts to DNR and end of life decisions despite their family members being sick and declining for quite some time. In my opinion, this topic should be brought up much earlier by their PCPs, when everybody is calm and can discuss options in peace and quiet.
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    I'm a fairly new nurse (just a few weeks shy of a year), working in oncology as well. The situations you've described are the hardest part of being an oncology nurse for me. Unfortunately, the providers I work with do not have end-of-life discussions with patients and their families until the patient is days or sometimes hours away from passing. I've watched multiple patients struggle and be miserable simply because they don't have adequate education about the severity of their disease process and the likelihood that treatment won't be successful. I wish DNR, palliative care and hospice discussions started at diagnosis, and that people understood that DNR does NOT mean "do not treat." While talking about end-of-life care isn't the most pleasant thing for many people, it would enable patients to make educated decisions regarding code status, hospice, treatment options, etc.


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