Code Status: When should we talk about it!
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 code status. As a student, the anticipation of a code being called is anxiety laden to say the least. In talking with staff it became apparent that no matter how many times they have been in a code situation it is equally as anxiety causing for them. Since starting on the unit I have witnessed two code calls and have been involved with calling the CCA down twice. Although none of these particular codes involved performing CPR, I decided to explore some of the ethical issues and communication barriers involved with code status. One particular patient was incapacitated and showed little hope for any recovery but yet had full code status. Both I and other staff expressed great concern of how a code would progress should this patient suffer respiratory and or cardiac arrest. In order to fully understand the ethical issues I felt surrounded this situation, I will present a relatively detailed history of the case prior to critically reflecting on the question of code status and CPR.
Just over two weeks prior to us caring for our 80-year-old patient, he was admitted to the coronary care unit (CCU) post MI from a small town hospital. After seeing physicians in our hopsital, he was deemed fit for a coronary artery bypass graft, times eight. From what I gathered in the chart, he had a history of hypertension and although recovering from a heart attack he was in sound mind prior to the surgery. On his first postoperative day he went into cardiogenic shock, and eight days later suffered a massive stroke. He required pleural drains, a tracheostomy, a dobhoff feeding tube and a heparin infusion. Days later he was transferred to the neuro unit with a Glasglow Coma Scale rating of three to six. He was occasionally a six when he would very slightly withdraw his right leg from pain. He was in persistent atrial fibrillation and had plus four oozing edema in all of his limbs. His hemoglobin was dropping and thus we were ordered to administer packed red blood cells. As I cared for him during the night shift I only encountered his family briefly, but while I was in the room I opened the door to any questions that they might have. In spite of my uncertainty with any potential I felt he had for recovery, I was able to explain his medications and need for a blood transfusion. The patient’s son expressed hope and excitement at the prospect of his father receiving a blood transfusion, stating “Oh, that’s great! That will perk him right up”. I was still unsure at this point if he remained a full code because his physician had not yet had an opportunity to discuss it, or if this is what the family wanted. Yet it became clear as the son further went on to talk about the recent death of his mother, and how they weren’t ready to let their father go. I felt strong empathy for the family at this point but questioned how forthcoming and honest the physicians involved in the case had been with them regarding not only their fathers minimal or non existent chance for recovery, but what code status really means. In addition, I wanted to explore what the nurse’s role is in code status decisions with physicians and their families.
It seems there is much confusion regarding the term DNR, particularly but not exclusive to patients and their families. Murphy & Price (2007) assert that although succinct descriptions and procedures are available for health professionals regarding DNR orders, they are insufficient. They further that due to our profound emotional discomfort with death, DNR orders are written not often enough or too late. Part of the problem roots in the confusion over what the term actually means. A DNR order is supposed to mean that in the event that a patient suffers a cardiac or respiratory arrest, CPR will not be initiated. A DNR order does not mean however, that the patient will not receive maximal therapeutic care and be left to die. I would further that it is this miscommunication that leads to families such as the one of our patients, to decide they want full code status. They had stated that they wanted everything done for their father, but one wonders if they knew the violence that can occur during CPR in a code situation and the evidence regarding outcomes, if they would still make the same decision.
Brindley, Markland, Mayers & Kutsogiannis (2002) stated that, “Resuscitation was never originally recommended for all patients, and its goal should be to reverse premature death not prolong inevitable death. The current situation is often to attempt CPR unless it is explicitly refused.” While Murphy, Murray, Robinson & Campion (1989) conclude that not only is CPR inappropriate for some patients, elderly patients with chronic or acute diseases rarely leave the hospital alive after CPR. With this patient, we all felt that CPR would only prolong the inevitable and furthermore would have caused undo harm on this patient after a sternotomy and the multiple other health problems he suffered from. With a GCS of three, not only did it seem unacceptable to have this patient on a regular nursing ward and not in intensive care, it seemed unacceptable that this family had not had the direness of their fathers situation explained to them in a manner in which they could understand. This was evident in their hopes of how a blood transfusion would turn things around for him. They were clearly unaware that he had suffered massive brain trauma from his stroke to which he would not recover.
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. Firstly nurses have a responsibility to be a patient’s advocate and that starts from the moment a patient is in your care (CNA, 2008). Prior to this patient being taken in for this very risky procedure, a nurse could advocate that the physician discuss advanced directives in a family conference, so as the family is not left to make those hard decisions which can often not be agreed upon amongst family members. Robinson, Cupples & Corrigan (2007) assert that is the lack advanced planning regarding CPR that leads to poor care when people have passed into an advanced stage of illness. Their research suggests that it is most common to postpone discussions about resuscitation until the patient is no longer competent. As it stands it is left to physicians initiate these discussions and research shows that many are uncomfortable doing so, which could be attributed to poor communication skills or a fear that they will undermine a patients hope by discussing resuscitation while they are still in the early stage of illness. Robinson et al. (2007) go on to say that it is often nurses who have to take the lead and bring resuscitation issues to the physician’s attention. Families deserve to know that their loved ones are unlikely to recover and it is the physicians’ responsibility to be honest and openly discuss this. It is proposed that physicians are reluctant to accept that their patients are in fact terminally ill and can no longer recover from what ails them. In contrast to doctors’ disease centered model of care, nurses’ holistic patient centered approach makes them more attuned to getting involved with end of life decisions, as they are likely better informed about a patients total physical condition and preferences (De Gendt, Bilsen, Vander Stiche, Van Den Noortgate, Lambert & Deliens, 2007).
Secondly both nurses and physicians have an ethical mandate for non-malificence Performing CPR on an elderly patient who has recently had a sternotomy and has no chance of recovering from a massive stroke would contradict our code of ethics. Advanced CPR has been proven to be a violent intervention that can break thoracic bones, puncture and collapse lungs, rupture pericardial sacs, cause burns and lead to permanent brain impairment (Davey, 2001). I question how we as nurses can continue this practice when clearly it puts us ethical dilemmas. Lazaruk (2006), a CCU nurse agrees that this harsh, life sustaining intervention does allow patients a dignified death and that CPR actually leads to significant harm to the patients. She concurs that when possible, code status should be address by medical residents as soon as a patient arrives at the hospital. It could become routine practice to allow patients to be involved in planning their care, and empowering them to make decisions about their own end of life care. Storch (as cited in Lazaruk, 2006) stresses that inappropriate use of CPR is an extremely troubling issue if not the most troubling issue for registered nurses. The CNA Code of Ethics for Registered Nurses (2008) compels us to respect the dignity of our patients and advocate for the use of appropriate interventions. Studies show that in Canada nurses are involved in DNR decision making only half or less of the time (De Gente et al.).
Despite all the evidence this practice continues. Storch suggests that perhaps the fear of death or failing keeps this practice alive, and I would agree. I think our society is very uncomfortable with the dying process. As previously mentioned, I had also cared for a patient who was CTC status. Unfortunately, this was the first time I had ever seen this. This patient received only treatment to keep her comfortable so as she could pass away peacefully, in a dignified manner, with her family at her side. She too had a massive stroke, although had maintained more function than the patient with the full code status. She had ten daughters who took shifts staying with her, holding her hand and providing care and love for her. I found the whole situation very touching, and it was refreshing to see a family so closely embracing the beauty of death as a part of life. As it turned out some of her daughters were nurses. I suspect that they are privy to the pain and suffering that the healthcare system can put patients through, even when they have no hope for recovery.
Obviously this is a complex issue, but with more education for both nurses and physicians on how to discuss code status and end of life care with patients and their families, we could make it a less distressing part of regular admission. If it was more commonplace and people knew that it was always discussed, then it would cause less fear and decisions could be made in a more timely fashion. I think we need to talk about death as a part of life and start treating all aspects of our patients, not just their bodies. As health care professionals I believe it is our responsibility to be honest with patients and their families so they can make informed decisions and ultimately ease our moral distress and their own. In an age where technology and health care advances can sustain life for so long, perhaps we could ease the fear of death and dying for patients, families, and healthcare providers and allow people to die with dignity.
Brindley, P.G., Marland, D.M., Mayers, I., & Kutsogiannis, D.J. (2002). Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ. 167(4). Retrieved July 26, 2008, from http://www.cmaj.ca/cgi/content/full/167/4/343
Canadian Nurses Association (2008) Code of ethics for registered nurses. Retrieved July 28, 2008 from http://www.cna-nurses.ca/CNA/documen...ics_2008_e.pdf
Davey, B. (2001). Do-not-resuscitate decisions: too many, too few, too late? Mortality 6(3), 247-262.
De Gente, C., Bilsen, J., Vander Stichele, R., Van Den Noortgate, N., Lambert, M., & Deliens, L. (2007). Nurses involvement in ‘do not resuscitate’ decisions on acute elder care wards. Journal of Advanced Nursing 75(4), 404-409.
Lauzaruk, T.(2006). The CPR question. Canadian Nurse, 102, 23-24
Murphy, D.J., Murray, A.M., Robinson, B.E. & Campion, E.W. (1989). Outcomes of cardiopulmonary resuscitation in the elderly. Annals of Internal Medicine, 111, 199-205.
Murphy, P., & Price, D. (2007). How to avoid DNR miscommunications. Nursing Management, 38(3), 17-20.
Robinson, F., Cupples, M. & Corrigan, M. (2007). Implementing a resuscitation policy for patients at the end of life in an acute hospital setting: qualitative study. Palliative Medicine, 21, 305-312.Last edit by Joe V on Dec 26, '08
From 'Saskatchewan'; 41 Years Old; Joined Mar '08; Posts: 5; Likes: 32.Dec 12, '08 by dotmedicrn, ASNGreat idea i wish as nurses we could talk more openly with our pts since we are the ones giving direct care and see the suffering first handDec 13, '08 by snevah99wow,well thought out,articulate,nice!!!Amen to your entire presentation.I wish we could get away from the popular myth of immortality(sp?) and give death and the dying process the same type of attention we give prevention and wellness!!Dec 15, '08 by SwampCat, BSN, RNVery well written and great info! Thanks for my daily dose of knowledge!Dec 15, '08 by wearyrnA Informative article! This subject has been a passion and concern of mine in my 35+years of critical care experience. I have always thought that a planned and tasteful presentation of the subject of DNR and advanced directives given to people (not at a traumatic moment) in education to help them make an informed decision. As well as more education and preparation of the nurses to make it not as uncomfortable. I loved the statement that we ARE the patients advocate and that is even in death. I could write a million thoughts on this but will say thank you again for your research and thoughts that were so well put on paper.
Dec 18, '08 by redheadedvixenAt the hospital I work for we DO discuss the DNR option with patients or their family on the day they arrive as part of the admission process. If the patient or their family tells us that they have made the decision to be a DNR we ask the Dr to write the order. If they have not made a decision and have questions we let the Dr. know or have one of our chaplains speak with them. This is the first time I as a nurse have been told it's ok to discuss DNR status with patients and am grateful to the organization I work for for giving me that ability. As a co-worker for this company I am truly given the opportunity to advocate for my patients on many levels. I wish more hospitals encouraged their nurses as mine does.Dec 19, '08 by lamazeteacherI have just been recertified in CPR, and although I haven't worked in the critical care areas for decades, I'd like to query the author's acceptance of DNR in theory.
There is no mention of anyone having medical POA (Power of Attorney), who could sign a form requesting DNR status for the patient, if there was none. By the age of 80, with an MI behind him and heroic surgery to be done (8 bypasses!), it seems that any physician worth his/her salt would have advance directives updated and in place, on this patient. Usually DNR means no chest compressions, or artificial ventilation, or AED, and that is explained (if not on admission to hospital) before or soon after admission to hospital. The family should be informed if DNR is in place, but occasionally someone may not have that information. With aged patients, I usually include the fact that ribs are often broken with chest compression, when explaining DNR to families.
For DNR to be upheld legally, not only must the physician order it, but the papers signed by the patient or his/her POA must be in the chart, which is labelled accordingly. Any patient without those, is given CPR. No confusion about that is appropriate at a time when it becomes evident that it might come into play.
Last night on "Private Practice" or "Grey's Anatomy" there was a dramatic scene during which a young man and his father were in disagreement about anything that might prolong the son's life. Dad wanted the patient (who seemed to have long suffered some chronic disease) to live, son thought it was best to go. The doctor didn't know what to do, but finally reached accord with them and stopped ventilation. Whew! All that should have been determined way before the inevitable conclusion to the disease was reached, and staff should have been clear about what to do.
However "should" and fact are oft in discord. I'll never forget a doctor who, in 1968, walked into the
oom of his patient during a full code response, and yanked the electrical cord of the defibrillator, out of the wall, furious that his patient, who suffered from cancer, kidney failure and advanced
cardiac issues was being subjected to "abuse". Enter DNR to the infant phase of CPR.......
Now there should be no confusion, after 40 years during which all healthcare providers must recertify every 2 years and get the latest information regarding CPR , so I was surprised to see the above article. It never has been easy to deal with death, expected or otherwise. I remember teaching hospital staff about it, when "Death and Dying" was called Thanatology (pre Dr. Kubler-Ross).
Individuals may never get comfortable about their roles, but procedures need to be clear and it needs to be known that, especially with elderly patients, it is appropriate for nurses to ask patients and their families if this important topic has been discussed and resolved. We have been given permission to educate patients and their families for many years now.
When something like the above described situation comes up, the first thing that broke down was communication. It appeared that the patient of advanced age had been in the hospital for 2 weeks, having treatment for cardiac disease (life threatening) and then precarious surgery for same. The only surprise is that the question of DNR hadn't been raised and resolved early on....... by someone
which indicates to me that some of us are still tippy toeing around death. That issue should have been #1 on the Plan of Care!
Nursing Schools had the subject on curricula for decades. Is there some reason that it is still unclear who does what?Last edit by lamazeteacher on Dec 19, '08 : Reason: clarificationDec 20, '08 by Chico David RNFirst, very well written and well considered piece. Second, I have never felt that it was not the nurse's place to discuss CPR/code status with the patient and family. when I have a patient with a terminal diagnosis who has not yet been made a DNR, I usually start a conversation with something like this: " Most people have some idea what sort of care they want at the end of their life and you need to understand that, as things stand right now, if your heart or breathing stopped your nurses would have to do the full array of CPR and defibrillation for you. If that is not what you want to happen, you need to talk with your doctor about it." I've never had a family or patient upset that I brought it up and I've been thanked many times. Many of them have filled out an advance directive but don't realize that has no real effect until orders are written for the current admission. they think the document expressing their wishes controls their care and aren't aware that it takes orders in the chart to implemement those wishes in practice.Dec 21, '08 by oramarThe docs really fall flat on their faces dealing with this stuff(DNR)in so many cases, so that is why nurses have to step up to the plate and deal with it. We are required by law to ask everyone about their living wills on admission. How come docs are not required to initiate this conversation in their offices? How about a little nudge from medicare and medicade in the form of financial incentives. I for one would allow an additional payment from medicare and medicade to cover the time and money spent letting people know their options.Dec 21, '08 by BluntForceTraumaQuote from oramarMedicare and Medicaid shouldn't have to give financial incentives for doctors to do their jobs. It is part of their responsibilty.The docs really fall flat on their faces dealing with this stuff(DNR)in so many cases, so that is why nurses have to step up to the plate and deal with it. We are required by law to ask everyone about their living wills on admission. How come docs are not required to initiate this conversation in their offices? How about a little nudge from medicare and medicade in the form of financial incentives. I for one would allow an additional payment from medicare and medicade to cover the time and money spent letting people know their options.Dec 21, '08 by Chico David RNI have to say, that at my hospital the Doc's are doing much better than a few years ago. Part of my job is doing the now-mandated education for all the CHF patients admitted to our hospital and I do a lot of looking in charts to identify those patients. I would say that I see documentation of a conversation about code status in more than half the H&Ps I look at. Ten years ago, it was more like 1 in 20. This is another case - like childbirth practices, and more humane treatment for breast cancer - where the docs have not led, but followed, dragged into doing what was right by patient consumerism and nurse activism. But at least they are finally getting it and the newer generation of Docs is definitely better than the old. So they are trainable, it just requires patience and persistance.Dec 21, '08 by lamazeteacherThe newer generation of physicians probably recognized that change is in the air regarding the need to work as a team for the good of patients. Since the "handwriting is on the wall" regarding future lower remuneration for them, the reason to go into medicine may now be to be the ability to make a difference in treating/healing humanity, and not the almighty million dollars a year.
So they'll be with us about what's really important about humane care. Yeah!Dec 22, '08 by organichombre, MSNFirst off I hope you submitted this to be published and secondly, Bravo! for the in depth research. AS ONE OTHER POST STATED THERE WAS A MASSIVE BREAKDOWN IN COMMUNICATION AND i'M WONDERING...???WAS THIS A TEACHING INSTITUTION? Sorry didn't mean to shout! This sort of thing happens more often in teaching facilities where pts become guinea pigs and if the families are not directly involved things happen that shouldn't. This is a great teaching example that I hope is shared throughout cyberspace! I teach critical care for a local BSN program and have lately began to include an entire clinical day reviewing DNR's, code dynamics, nurse-pt-family interactions about death and dying and this essential need for communication. For all those newbie nurses out there...remember this...you MUST think of what would happen if it were your loved one lying there! So what if you **** off an attending or fellow, the family will remember your compassion and dedication. Peace out!
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