Code Status: When should we talk about it! - page 3

by klg315 | 11,263 Views | 29 Comments

During the past month of my practicum on the neurosciences unit, I have seen and cared for numerous patients. Some have had do not resuscitate (DNR) orders; one had a compassionate terminal care (CTC) order, and others a full... Read More


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    I just wanted to add to the many comments commending the author on the well thought out and well researched article on this very important topic. I'm actually presenting a CEU for nurses in April and will use this article (and it's references-thanks!) in my presentation.
    One poster stated advanced directives and code status are not the MD's decisions- no! Of course not- it's the patient and the family. But IT IS the responsibility of the MD to present accurate information re: pt condition and prognosis and choices of treatments. I work in bone marrow transplant and am SICK of the MD "oh, he's got a treatable disease." Smile. AML (form of leukemia) has a 20% five year survival rate. Our patients don't know that.
    It's been a miserable Christmas and weekend. Our beloved pt with AML coded and died Christmas- her husband and son just stunned. We had 3 more codes over the weekend and 1 didn't make it. Well well. Isn't that what the author stated? CPR was NOT intended to be used on one who is terminally ill, ie refractory cancer.
    Our beloved lady died without her friends- all who are in shock and grieving. "IF only we could have seen her 1 more time, held her hand, told her we love her." Palliative care/hospice care- humane, compassionate and vastly underutilized. I believe it's because we haven't gotten the message out- that you DO have a choice. Tube down throat and broken ribs on the way out. Or morphine, cup of tea and your dog and cat and grandchildren cuddled up next to you. Comfortable and dignified.
    We see way too much "ER", "Grey's Anatomy" etc etc. that show coded people waking up and walking out. Come on people! We need a dose of reality and some education to go with it...
    sorry for the long post. Can ya tell it's been a tough week and I'm a bit interested in the topic? :yldhdbng:
    mandykal, Need2Wings, heron, and 1 other like this.
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    Doctors are sold the image of themselves as knights in shining armor battling disease. They have lost the image of themselves as people who try to buy their patients the most good time humanly possible, and sometimes that means taking off the suit of armor and doing nothing.

    Until medical schools shift their focus, we're going to be stuck in the role of patient advocate, asking doctors just what the hell they're doing offering heroics as the standard of care when common sense would dictate they offer the patients and their families a choice and informing those patients and families directly that a choice exists.

    It will continue to put us into a terrible position, but it's part of the job for the foreseeable future.
    oncnursemsn likes this.
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    Quote from oncnursemsn
    I just wanted to add to the many comments commending the author on the well thought out and well researched article on this very important topic. I'm actually presenting a CEU for nurses in April and will use this article (and it's references-thanks!) in my presentation.
    One poster stated advanced directives and code status are not the MD's decisions- no! Of course not- it's the patient and the family. But IT IS the responsibility of the MD to present accurate information re: pt condition and prognosis and choices of treatments. I work in bone marrow transplant and am SICK of the MD "oh, he's got a treatable disease." Smile. AML (form of leukemia) has a 20% five year survival rate. Our patients don't know that.
    It's been a miserable Christmas and weekend. Our beloved pt with AML coded and died Christmas- her husband and son just stunned. We had 3 more codes over the weekend and 1 didn't make it. Well well. Isn't that what the author stated? CPR was NOT intended to be used on one who is terminally ill, ie refractory cancer.
    Our beloved lady died without her friends- all who are in shock and grieving. "IF only we could have seen her 1 more time, held her hand, told her we love her." Palliative care/hospice care- humane, compassionate and vastly underutilized. I believe it's because we haven't gotten the message out- that you DO have a choice. Tube down throat and broken ribs on the way out. Or morphine, cup of tea and your dog and cat and grandchildren cuddled up next to you. Comfortable and dignified.
    We see way too much "ER", "Grey's Anatomy" etc etc. that show coded people waking up and walking out. Come on people! We need a dose of reality and some education to go with it...
    sorry for the long post. Can ya tell it's been a tough week and I'm a bit interested in the topic? :yldhdbng:
    I wholeheartedly agree that dnr and other advance directive discussions need to happen way sooner than is often the case.

    As a hospice nurse, I've seen the chaos that ensues when such decisions are left to the bitter end. Too often, our palliative skills are wasted when a pt comes to us within days, sometimes hours of death. In those cases, about all we can do is hold the families' hands and medicate the pt to a fare-thee-well trying to achieve some semblance of a peaceful death. Sometimes that's unavoidable ... as in cases of fatal trauma or sudden catastrophic illness ... but usually not.

    I think my previous post meant to address those situations where we, as professionals, can see a bit further down the road and assume that all it takes is a candid description of the probable course of a disease and voila!, the family makes the leap. Many of us tend to become a bit outraged when a pt or family insists on a full code status even in the face of declining condition and an increasingly bleak outlook. We throw around such words as "selfish"
    or "unrealistic" without recognizing the fact that these decisions are part of a grieving process...and that it takes the time that it takes.

    Repeated discussions over time are usually necessary to help the pt/family wrap their minds around what's going on. MDs need to take the lead, for sure ... and many of them are as unable to grapple with this as the families and the pts ... often because they don't want to take away all hope prematurely.

    In hospice, we are not allowed to require that pts be dnr in order to receive services. I've participated in my share of deathbed code discussions ... a painful and unnecessary added strain in what is already an unbearably sad time.
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    WOW, absolutely wonderfully written and well researched, thank you for sharing it.

    This was my family just over a year ago with my oldest brother, I thought he had a DNR already, however he ended up in ER, coded and was down for an unknown amount of time(not being monitored-but thats another story). Full code was obviously performed he ended up vented and in ICU. Along with my dad, sister, brother and neice we drove down(we live in Michigan, he lived in Tennessee). He was basically unresponsive, his wife was in denial. I remember the nurse and the physician(ICU) talking to his wife and I in the hall but she didnt get it. I remember the nurse saying "sometimes our interventions and technology interfere with what life has planned". I knew what she meant. There were many times during the 10 days trecking to the ICU 4x day for visiting hours that I felt very alone, I remember having a conversation with my brother just about 6 weeks before this incident when he told me he was sick of being sick, he said it sucked for his kids but he was done with the whole business. I tried to talk to my sister in law but she was convinced he was going to recover, go to rehab and be ok, although she said he might not be 100% ever again she thought he was going to be functional on some level. Even his surgeon came in with what I am calling false hope and they put in a GI tube, I was furious. He was still on the vent and going down hill fast, he didnt tolerate the NG tube so they had discontinued that and when they began using the GI tube no surprise to me (and only a nursing student) that wasnt tolerated either.!!*&^*@! Finally maybe about day 8 my sister in law, neice and I were talking and she asked me what I thought so I said I know he doesnt want to live like this and THIS is what we have-- no change since he has been there, his body is giving up and they are doing dialysis (which he made very clear he never wanted) He was weaned off the vent in here somewhere and to their suprirse he continued breathing on his own. She agreed to the DNR and he passed away 2 days later. ( I think he was waiting for my youngest brother to get there)

    Now I do want to say that perhaps some of what happened was for the benefit of my family as we would not have had the chance to say goodbye like we did had he died in the ER. I would however wish we would have been able to initiate palliative care instead.
    oncnursemsn likes this.
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    (((Need2wings))) I am so very sorry your brother and your family had to go through this. Every person should have a Health Care Proxy- someone who WILL carry out your wishes- and it may not necessarily be your next of kin. I know my dad or sister wouldn't carry out my wishes. It should be clearly documented and in a place where easily found, ideally travels with you to the hospital. My heart goes out to you and your family.
    We had a little old lady transferred from a nsg home- 89 and frail. Admitted with "Mental status changes." I had her the first day, and she bit and hit me when I was adjusting her IV. Came in day 2 and her cardiac monitor is showing HR of 42 and irregular. Oops. The intern was on the phone. Her Health Care Proxy was in Italy! What? Was she a full code? You got it. We coded her and transferred her to ICU. Very sad. She died 5 days later- tubed and paralyzed.
    Has anyone heard of "FIve Wishes"? It's a beautiful document- costs $5 and unfortunately isn't recognized in MA. It's a good guideline though for those who want to stipulate what exactly they want when it looks like death is impending.
    Need2Wings likes this.
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    "Although it is not a nurse’s place to discuss prognosis with the families prior to the physicians doing so, it is my belief that DNR orders have many implications for nursing practice on an ethical level."

    First, let me say how impressed I am with your diligence in researching this critical area for all health care professionals. You determined the importance of being well-informed for yourself and then passed the information to all the nurses who frequent this site. Thank you so much! Even more, thank you for being committed to doing the right thing for your patient at the right time and in the right way- the definition of integrity.

    I would like to take your quote above and ask our peers what their thoughts are on this issue. Is it truly not the nurse's place to raise these issues with patients before our physician cohorts do so? What if they don't? What if they are not comfortable having these conversations with families, therefore they postpone the inevitable, prolonging pain and suffering for their vulnerable patients.

    The longer I have been practicing as a nurse, the more convinced I become nurses are just as well-equipped to discuss the plan and probable course a patient will take, along with the possibilities, as physicians. Nurses are the ones who are with patients for hours and days and months at a time. We are more acquainted with the nuances of family dynamics and the ability of patients and families to absorb information. Too often, we are not included in the conversations about plans of care and outcomes that occur among physicians in hallways and over coffee.

    What do you think? Should nurses initiate these conversations or is this better left to those with MD behind their names?
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    Very well written piece.
    It is always within the nurse's scope of practice to discuss "code" status. In some states it is also manditory to have it entered into the hospital chart on admission along with POA information just in case. ( OHIO )
    CPR is very brutal, gruesome and it doesn't always do any good.
    If CPR saves just one life in 100 then I am happy to have practiced on the 99 so that a new mom can go home from the hospital with her newborn, or give that grandpa another hug on grandparents' day, or that coding teenager a chance to prove he does know how to drive, or give the transplant team time to find reciepients for the organs in the body of the one we couldn't completely save. If you save one life you might save 10 more you just don't know. So I will continue to do CPR if code status is not discussed because it is my job.
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    really great!!!!! it was so educational and informative...that medical practitioners should keep in mind especially physicians and nurses....i truly agree, we should treat our patients as human being in the very essence of the word and not just as bodies/commodities...dying is a part of life that everyone need to face and nurses had a great role in the process...congratulations and thank you for the enlightenment...
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    I always assumed that this was now addressed on hospital admission everywhere. It definitely should be. In home care we ask about this on admission for every patient, though often they say they have not thought about it and we give them additional info. about living wills. It is awkward, but I got much more comfortable discussing it when I worked in hospice and I think it is easier to ask when the patient is not facing imminent death.
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    Personally, I think Code status should be talked about at the time of admission if it is an admission on a short term
    basis. If it is a long term basis, with in a month after an admission in order to get over the shock of putting some-
    one into a long term setting. One nurse told me recently "doctors don't do death." I swear that's true. Some nurses
    don't due it either. Unfortunately death is a fact of life like taxes are so we all better get use to it whether we like it
    or not. When I had my hysterectomy at 39 years old, I told the nurse that I wanted to be a DNR, she told me to
    discuss it with the doctor. I'm studying for my PhD and I'm close to doing my dissertation and I know that talking about code status will be an aspect of it.


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