Blue about Code Blue

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MomRN0913

1,131 Posts

Specializes in ICU.

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.

KelRN215, BSN, RN

1 Article; 7,349 Posts

Specializes in Pedi.

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 My very favorite patient died in the ICU on BiPAP- her parents had rescinded her DNR several times and it had finally been reinstated.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.

NurseDirtyBird

425 Posts

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.

Specializes in ED.

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.

One1, BSN, RN

375 Posts

Specializes in Emergency, Pre-Op, PACU, OR.

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.

grandpaj

206 Posts

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.

BrandonLPN, LPN

3,358 Posts

Maybe med school needs to spend more time on coping with end of life issues.

The nursing model of healthcare seems to have a more realistic view of dying than the medical model does. Why do so many doctors seem to want to fight to the bitter end?

It'd be interesting to see some MDs' opinions on this subject.

PMFB-RN, RN

5,351 Posts

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
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.

*** Oh ya, been there, done that. A few times it was I could do to stop myself from yelling "THAT"S BS!" when listening to a physician (usually not an ICU doc) tell families something like that. I WILL give families my educated opinion on the likely outcome for their family member. Occasionaly this leads to them confronting the physician and that makes him angry with me. Oh well that's why I get paid the big bucks.

I know there are worse things than death. I have seen them and cared for them.

*** Right? We should put that on a T shirt.

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 too have heard that "what do you mean he is on life support!?" The term "life support" doesn't mean anything to us. It's like a medical TV show term that we don't use but families often use it.

I

PMFB-RN, RN

5,351 Posts

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Will there come a time here where payment dictates what is done?

*** Wouldn't that be great!? Can't come soon enough as far as I am concerned.

Specializes in LTC Rehab Med/Surg.

If the pt is alert, oriented, and want a full code, that's what they should get. Even if their choices are hopeless.

The scenarios that truly bother me, are the ones involving pts who are basically already gone. They no longer even remember who they are, but the family demands "everything be done". They don't want to make the hard decisions, so they just don't. I've often wondered if the choices would be the same if the family had to pay. Even a portion.

SaoirseRN

650 Posts

If the pt is alert oriented, and want a full code, that's what they should get.[/quote']

Which is fine, as long as they've had the proper education about their choice.

I'm a nurse but I always think about my grandfather when it comes to this exact situation. He was admitted with acute renal failure and upon admission they found stage 4 lymphoma. He had a long history of health problems with multiple surgeries. When I went to visit him in the hospital I asked his nurses about his code status and was surprised to find that he was full code. When I asked my family member (POA) about why he was a full code, she didn't didn't even know what a code was! After I explained what they would and could do, she was horrified. After speaking about the status with other family members and his longtime doctor, it was changed. A lot of times we have patients who are still full code because only an attending can change code status and it simply doesn't happen.

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