Do you approach patients or families about code status?

[RNinICU]

In your hospital, who approaches patients and/or families about the patient's code status? If a patient takes a turn for the worse, and some one needs to find out how aggressive the treatment should be, do nurses or doctors talk to the families? Or if a patient has been on support for a long time and is only being kept going by the machines, who talks to the family about discontinuing treatment? As an ICU nurse, I have often updated families about a patient's status, and discussed the option of making a patient a DNR or discontinuing an ineffective treatment. Only one of our docs has a problem with the nurses talking to families about code status. He is an older doc who seems to think that the nursing staff is usurping his authority. My SIL works in another state, and she tells me that nurses at her hospital never discuss code status, only the docs do this.

I am not talking about giving complicated details of treatments and procedures, I am just talking about finding out from families what their wishes are regarding code status.

[mattsmom81]

I'm an ICU nurse and I try to gain rapport with my family early. I am also big on education and explaining situations to families...even when a bad outcome is expected, they have a right to know what's going on and have the opportunity to ask questions. I also involve our chaplain if they wish.

If the patient outcome is not looking good I make it a point to speak honestly to the family (and the patient if they are alert) about their wishes....I stress we want a clear picture of everyone's wishes so we can do what patient and family wish if/when the time comes. I've gotten very comfortable with this over the years.

I don't wait for the doc...I'd wait forever. I get the info and then notify the doc of the patient/family wishes and take care of the legalities/paperwork. Every patient has the right of self determination and I don't like waiting til the last minute to address end of life issues.

Some facilities may frown on this but in my parts the docs appreciate the nurse running with the ball here so we're all on the same page.

[nimbex, RN]

Morning, It's my belief that every hospital "dictates" the culture in who addresses code status. So pay attention to the culture first, second, ask a seasoned nurse there what is their normal practice.

In my hospital, too many MD's differ so this is what I do... mind you, in your culture it may not be accepted.

Once I make the call that "the talk" is required, I approach the next of kin (I work in the south) and ask them what the MD has told them of prognosis, If they have an understanding of instability, or coding the patient will not change the ultimate outcome, I ask if the patient has ever discussed with the family what they would want done in this situation...

Many families state "he never would have wanted this!".. The sudden progression of disease and treatment required vents, maxed inotropic support which was unanticipated.

If they state this, I ask If I may explain what a code involves and describe it... then allowing questions. I then ask again, do they think the patient would wish heroic measures and ask what do they want done.

At this point, you have not crossed the line, only asked pertinent questiones and educated the family. If they voice not wanting "all that", the code done, I encourage them to discuss it in private... not all present will state their concerns in your presence. If I am reapproached with a dislike of a code, I then call the MD, state the family had been in discussion of code status and wish to speak to them about DNR status. The MD will know if a phone of face to face meeting is required.

Sorry, this is long

If the patient never discussed their wishes and/ or the family harbors false hope or is not ready to give up, I explain that (stability status depending) death is imminent, we will do everything to treat... "may I discuss what a code means" some have no idea and despise the process and negatively voice their opinion, where I call the MD, some say yes... do everything.. even if the patient has metistatic CA, on the vent for weeks and is now maxed on drips.

When you have your "in denial or do everything for the hopeless cause" family, and coding is immenent, I ask if they wish to be present... YES!!!! may nurses feel very strongly about family NOT being there during a code... my experience of 7 yrs. ICU shows that when prepared about a code, sometimes briefely and given a choice, it is those family who can't let go to a hopeless situation when witnessing what really occurs are the ones to say, "please stop and let them go". This is especially true when you have coded the patient multiple times in an hour and now give the family a choice to sit at the bedside and witness what occurrs instead of sitting in the waiting room, they can see what their loved one is being put through because they can't let go. This is especially true when you are coding a patient continuously untill the last sibling can arrive from out of town.

We are lucky that we have a patient relations person or supervisor to be paged to be a FAMILY ADVOCATE during a code.

Please understand... it is NOT routine that I let families watch, it is under those special circumstances only, I personally disagree with family present, but the above situations throughout my experience has shown me it gives family closure that more that they expected to be done was.... Many can say goodbye than, stopping a code in progress rather than saying keep trying from a waiting room.

It is so much to consider, I could writte pages, I never force or coerce a family based on my beliefs.

In the case of an MD not being comfortable to approach the family, realize they are human too... Many of these MD's have know the patient and family for years and are greiving themselves. ask if you may approach the family about code status if the MD is uncomfortable, but ask if they will remain available to answer family questions should they arrise.

In the case of the MD who gives false hope and will not make the patient a DNR, you have an ethical dilema, consult your supervisor or manager for guidance before proceeding, your chain of command is ALWAYS an excellent resource before you tread murky waters. If death is not immenent, some hospitals have a confidential ethics committee who can review your case, I have uses this is NY

Being a patient and family advocate with end of life decisions is very difficult. I hope this has helped..

Carol

My answer to you, long winded,

[thisnurse]

nobody likes doing this. not us and not the docs. where i work it is the doc who discusses code status with the family. but i have done it as well.

ill say something like

"have you given any thought as to what you want to do now regarding resuscitation?"

i just let them vent after that. i answer questions if they have any and i just listen. if they decide to make the pt DNR i call the doc and get the papers.

i cant say i really hate this. what i really hate is trying to bring back a pt who is dying anyway...especially when they are in great pain.

[caroladybelle, BSN, RN]

I am an Oncology nurse, and while it is the MDs responsibility, it is one that they are notoriously lax about. As I usually have some rapport w/ family/patient, I frequently will bring it up. Most physicians appreciate Nursings input. I have had more than a few primary MDs - when I have called about a patient concern - say that the code status needs to be addressed and "I don't understand why it hasn't" - you really want to say why haven't you - you idiot.

I also have at least a few MDs that keep their patients a full code despite the patients & SOs wishes to the contrary - the MD doesn't "believe in" DNRs. It is my duty to my pt to push the issue to get a DNR order. It doesn't win me any friends among the medical staff, but my conscience has to guide me and I can sleep easy.

[NRSKarenRN, BSN, RN]

nimbex,

What great advice and common sense you showed in your post. Having been practicing as you described for 25 years.

Will never forget the 19 yo oncology patient from out of state area that I coded for the SEVENTH time in two days (on nights of course, pulled to floor) in 1979 because the ONCOLOGIST DIDN"T BELIEVE IN DNR STATUS. After the family witnessed the 6th code, they wanted to stop all aggressive treatment. I called the resident and explained the family's desire. Told the family if code called again before order written, to just tell the team assembling NO. An hour later code was called as no order yet written. Nurses just stood outside doorway, intern tried to force himself in room with crash cart. Father of patient stood spread eagle in door way blocking entrance and Mother flung her body over sons shouting NO, NO. What a horrible and UNNECESSARY SCENE for this family to carry with them forever. Meeting was held with administration, docs, nurses and patient family with outcome Ethics committee was formed and Pastoral Care team later developed.

For those nurses uncomfortable with discussing DNR status, consider taking an Intro to Hospice course or Death and Bereavment inservice---invaluable to my practice.

[thisnurse]

what a horrible way to lose your son.

[micro, RN]

Originally posted by NRSKarenRN

nimbex,

What great advice and common sense you showed in your post. Having been practicing as you described for 25 years.

Will never forget the 19 yo oncology patient from out of state area that I coded for the SEVENTH time in two days (on nights of course, pulled to floor) in 1979 because the ONCOLOGIST DIDN"T BELIEVE IN DNR STATUS. After the family witnessed the 6th code, they wanted to stop all aggressive treatment. I called the resident and explained the family's desire. Told the family if code called again before order written, to just tell the team assembling NO. An hour later code was called as no order yet written. Nurses just stood outside doorway, intern tried to force himself in room with crash cart. Father of patient stood spread eagle in door way blocking entrance and Mother flung her body over sons shouting NO, NO. What a horrible and UNNECESSARY SCENE for this family to carry with them forever. Meeting was held with administration, docs, nurses and patient family with outcome Ethics committee was formed and Pastoral Care team later developed.

For those nurses uncomfortable with discussing DNR status, consider taking an Intro to Hospice course or Death and Bereavment inservice---invaluable to my practice.

nrsKaren.......

wow......

had to repeat to just reread and reinforce myself..........

I do not have trouble discussing in anyway advance directives and anything else related to it today, but it has taken a few years of seeing too much.........to bring more ease to it........

Ethics committee......wish that they had all the answers, but we can all do only the best that we can do.............

wow and i state again, kudos and love to all and strength for all that we see and deal with daily.............

keep on keepin on.......

micro

[puddlesrn]

I am a manager of an ICU. Our staff approaches pts and familys about code status. If we left it to the docs it would never happen. All my staff do a wonderful job with this and the doctors appreciate the effort. I also think that nurses know who needs to be approached and who doesnt and i think that this comes with experience. Also i do not hesitate to ask because it is the pts choice!! and i feel proud to be there to offer this right to the pt. Remember that we are the pts advocate....