Slow Codes - page 5

Just wondered what kind of response I might get from this title. Yes---I was a part of several on the night shift. They usually involved 80+ year old people with terminal illnesses who had idiot... Read More

  1. by   TazziRN
    Actually, it's not our place to have those conversations, Thang. The docs should be doing that with the families. We get involved only when the family asks questions.
  2. by   queenjean
    Quote from siri
    Why not?
    Because he felt her sterum disintegrate beneath his hands; when you put your hand on her chest while they were bagging her you could feel all sorts of crepitus. She was a skinny little thing, you could see things weren't right without even touching her. There was no need for a chest xray, her sternum (and ribs, too, you are correct) were in pieces. She was physically unable to withstand CPR. That's what I mean by she was not medically able to be coded successfully. I would have felt very wrong performing chest compressions on her. Obviously the physician felt the same, because he called it pretty quick.
  3. by   queenjean
    There are all sorts of continuing ed classes and conferences on death and dying. Any sort of palliative care conference will discuss this.

    I would disagree that it isn't our place to discuss this with the family. Often this has been discussed with the family exhaustively, by the physician, social work, chaplin, et nursing staff. And still there are questions, follow up questions, and they seem to often want them answered at three a.m. Having some guidance et education on how to discuss these issues, to reinforce the previous teaching and discussions, is very helpful, I think.

    I don't have as much experience as many here, with death and dying. Our floor is an acute care medical floor. We don't code that many people. If they start to head south, we either send them to ICU or, if appropriate, the palliative care unit. The implementation of a rapid response team has decreased our codes even more. I feel like I have quite a bit more to learn in terms of supporting families during this time. I'd like to attend the palliative care conferences in the area, but so far all the CEU-offering conferences have fallen on bad weekends for me. I wish our hospital would do more to help those of us on the floor with this. Their standard line is that, if we are uncomfortable with answering the questions, we should refer them to the physician, social work, et/or chaplin. Yeah, in theory. But when someone's having a crisis at 2 am, I can't just tell them I'll refer their questions to social work. Who won't be here for two days because they don't have weekend hours. The doc on call isn't their physician. Basically they are left hanging.

    I feel very inadequate in these situations. I suppose some of that will simply resolve with more time and experience. But I hear your pain, Mrs.Thang. I'd like a little more guidance on talking to and supporting patients and their families in these types of situations.
  4. by   TazziRN
    Quote from queenjean
    I would disagree that it isn't our place to discuss this with the family. Often this has been discussed with the family exhaustively, by the physician, social work, chaplin, et nursing staff. And still there are questions, follow up questions, and they seem to often want them answered at three a.m. Having some guidance et education on how to discuss these issues, to reinforce the previous teaching and discussions, is very helpful, I think.
    I believe that's what I said.......
  5. by   queenjean
    Quote from siri

    Age does not matter.
    I think age does matter in terms of ability to heal from the physical effects of a code; so does co-morbidities. I would never NOT code someone just because of their age. And we attempted a full out code on this little lady; it was just quite obvious from the moment he attempted chest compressions that her body was physically unable to be coded. At that point, there wasn't much good we could do. I still feel that way.
  6. by   queenjean
    Quote from TazziRN
    I believe that's what I said.......
    Sorry, I guess I misunderstood you.
  7. by   sirI
    Quote from queenjean
    Because he felt her sterum disintegrate beneath his hands; when you put your hand on her chest while they were bagging her you could feel all sorts of crepitus. She was a skinny little thing, you could see things weren't right without even touching her. There was no need for a chest xray, her sternum (and ribs, too, you are correct) were in pieces. She was physically unable to withstand CPR. That's what I mean by she was not medically able to be coded successfully. I would have felt very wrong performing chest compressions on her. Obviously the physician felt the same, because he called it pretty quick.
    The point I'm trying to make is that just because there are complications of CPR such as fx ribs, etc., one continues compressions.

    CPR is ineffective w/o compressions. Result=death.

    There is not a medical indication written to halt CPR just because the compressor fx ribs/sternum.

    I'm just trying to educate that fx ribs, etc. is a complication of CPR and does not warrant stopping/slowing down/letting up on compressions.

    I totally understand what you are saying in regards to the condition of the patient with poor prognosis and no possibility of a successful outcome regarding CPR. As for the physician calling the code, I have to agree with that.
  8. by   Daytonite
    Quote from MrsWampthang
    . . .is there any training you can get to help families make a humane decision that they can be comfortable with? I;m not even talking about terminal weans, which are a whole 'nuther situation, just helping families to see that making their loved one a DNR is really the best thing for that patient.
    I'm not sure about any specific training with regard to this. A course or book on thanatology might be helpful. My guess is that like most skills in nursing it takes rolling up your sleeves and digging in, correcting your practice from errors you make, searching out reading material for more information and always being ready to make another go at it.

    Your post sent me to my care plan references and I was particularly looking at the ones pertaining to death and readiness for death. Some of the nursing interventions (and these are independent nursing actions) mention helping the patient to redefine their main life goals, adopt realistic goals and recognize ones that are impossible to achieve, help patients with life review and reminiscence, encourage them to express their feeling of fear and validate it, to help with making contact with death planning organizations (funeral arrangements), encourage the patients and family to talk with appropriate professionals about areas of concern and teach them about options for care and such things as advance directives. If we were in nursing school we would be told to explore any resources we could find on these interventions to find out more about how to initiate them.
  9. by   CHATSDALE
    muff was right about addressing this preneed, and age doesn't matter, i have had a brain dead 20 y/o after a jack hit his head while changing a tire
    as a nurse you are an educator too and encourage your patients to make up their own mind about what they want..tell them there is no right or wrong but that it should be there in black and white so grieving relatives don't have to make that kind of decision in a stress driven time
    i think that the decision that all people in nursing homes should be a dnr is gross . that is something that should be decided on a case by case basis
    families that don't make the decision [dnr] in the face of reality are not really ignorant or selfish for the most part, they just have not reached the 5th step of acceptance...not everyone in the family will reach that point at the same time..again that is eased if wishes are formed by patient ahead of time and if one person is given the authority to make decisons
    back to op, it has been years since i have seen a 'slow code' they were frequent when i first started nursing but they were never written they were usually agreed by md/staff..but now they are not legal and if you do something when you don't have a legal leg to stand you stand a very good chance of losing your license and then you won't be any good to any other patient
    i have partiipated in codes post cabg when the sternum was split from here to there sometimes you do what you have to do
  10. by   tytkhat
    I remember my second year as an LPN on a med surg floor, we had a client in his mid 90s that coded. There were not enough RNs and so I as called to do compressions. Well, needless to say I was traumatized after I cracked several ribs but continued compressions as if he were 60 years younger. One of the RNs giving meds said to me after the code was over (did not make it), that I did not have to compress like I was trying to bring him back, as they were considering a 'slow code'. Of course this infuriated me and I told her that that was BS-either the pt is a FULL code or they aren't, and I dont recognize the term 'slow code'. The attending overheard our chatter and intervened, agreeing with me fully, saying that if you participate in a code, you have to advocate life and fight for the pt, otherwise why bother with sub-standard morals and practice...wow.
  11. by   Rnandsoccermom
    Unfortunately, sometimes families will not make their family member a DNR out of guilt for not being who they should have been when that person was well. Seen it happen too many times.

    Was at a code recently, 78 year old, multiple comorbidities including chronic renal failure, htn, diabetes, CAD, PVD, hospitalized for a month. Unresponsive, trached on a vent, maxed on Levo, Dopa and Phenylephrine. Became brady-asystolic 3 times in 2 hours. Pumped epi and atropine in, did CPR. Skin cold, extremities mottled. Spoke with family 3 times regarding the codes and changing the code status, they refused.

    It was sickening and inhuman. Say what you want, we were not helping this patient, only prolonged the inevitable. We are human, not gods, we can't fix everything. Knowing our limitations is just as important as knowing our capabilities. I would have participated in a slow code in a heart beat in this situation.
  12. by   Daytonite
    Quote from Rnandsoccermom
    Unfortunately, sometimes families will not make their family member a DNR out of guilt for not being who they should have been when that person was well. Seen it happen too many times.

    Was at a code recently, 78 year old, multiple comorbidities including chronic renal failure, htn, diabetes, CAD, PVD, hospitalized for a month. Unresponsive, trached on a vent, maxed on Levo, Dopa and Phenylephrine. Became brady-asystolic 3 times in 2 hours. Pumped epi and atropine in, did CPR. Skin cold, extremities mottled. Spoke with family 3 times regarding the codes and changing the code status, they refused.

    It was sickening and inhuman. Say what you want, we were not helping this patient, only prolonged the inevitable. We are human, not gods, we can't fix everything. Knowing our limitations is just as important as knowing our capabilities. I would have participated in a slow code in a heart beat in this situation.
    I totally understand and have seen what you are saying. I stood by in helpless horror as one of my patients stopped her dialysis treatments and was dead in a week. I worked on a stepdown unit where we had a vegetable patch of patients that lingered for days, weeks and months, many full codes. However, if you are heard AND witnessed doing this slow code business by someone who is liable to blow the whistle on you then you can kiss your license and your nursing career good-bye. A place like this forum where we are anonymous might be a safe place to admit what we truly feel, but I wouldn't be so arrogant and proud to announce something like this to coworkers.

    What my mother, who was an ICU nurse, and I learned from seeing all this kind of stuff at work was to have durable powers of attorney put in place for ourselves, know our families are aware of it, know who among our families does or doesn't agree with it and make sure we have physicians who are going to honor our wishes. Yet, I can't tell you how many nurses I've worked with who haven't done this or who have a spouse who has openly told them that they would do everything possible to keep them alive if they were in that situation. Over my career several of the big right to die cases were national news headlines, one geographically close to home, and it lit a fire behind me to get my documents in place. It still amazes me that many nurses still haven't worked this situation out in their own lives. We have no right to make that decision for the patients we care for and, yet how many have finalized and committed to that decision for themselves which they do have the absolute and legal power to do?
    Last edit by Daytonite on May 21, '07
  13. by   ShayRN
    Quote from karenna
    Just wondered what kind of response I might get from this title.

    Yes---I was a part of several on the night shift. They usually involved 80+ year old people with terminal illnesses who had idiot families that wanted them coded aka tortured before they went to Jesus.

    I understand your feelings, I really do! As a Hospice nurse, I think the most couragous thing you can do is let nature take its course. Just because we can keep some people alive, doesn't mean that we should. HOWEVER!!!! My mother has told me more than once that she wants everything done, no matter how hopeless the situation. So, I will honor those wishes to the best of my abilites. While I would probably look the other way if I found out about a "slow code, " I can assure you my stepfather wouldn't.

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