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.