Why do we do codes?

Nurses General Nursing

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prmenrs, RN

4,565 Posts

Specializes in NICU, Infection Control.

I was present @ many codes, both adult and neonates. The babies always do better (virginal coronaries, non smokers/drinkers, cuter). The adult ones I went to fell into 2 categories: nothing went right (nurse assigned to the pt disappeared, laryngoscope light bulb went out 2 secs after it was checked, crash cart was a mess, etc.) and the patient lived to get to the ICU @ least; or everything went perfectly, pt died anyway. We only think we have control over stuff.

My mom was being admitted to the ICU a few years ago, the nurse asked me if she was a code; I knew she had an advance directive, but I didn't have it w/me, so I just told the nurse not to "break" her. She had osteoporosis, it would have been very easy to do. Nurse knew exactly what I meant.

Guest219794

2,453 Posts

What a great topic!

I was in shock my first code here in the US, the patient had a living will that said DNR. I asked the physician after why we coded a DNR patient, and he said because the daughter demanded it, and that the patient is going to die either way, but if we didn't she would sue. I was flabbergasted. Another time, we coded an 80+ year old dementia patient because her family was living in her house cashing her social security checks, stayed in hospital vegetative for over a year ...

I have been in critical care for almost 30 years, can't even begin to count the number of futile frustrating codes I have done. Like others have pointed out though .... once in awhile one makes it with no deficits, that is a rarity, but definitely a win.

As you continue your nursing journey you will struggle with futile care decisions until you retire.

What a ramble, maybe I should put in paragraphs so it's not a wall of text .... done.

Cheers

I am pretty sure this is assault, and people get away with it because the victim has no advocates. I have participated in these assaults.

OP- if your question is why we work futile codes, or codes in which "success" is a negative outcome for the patient: That is the system we work in. Do your best, and consider it practice for the occasional code in which you save a live and they and they live happily ever after. That is pretty cool. You will like it.

blondy2061h, MSN, RN

1 Article; 4,094 Posts

Specializes in Oncology.
I am pretty sure this is assault, and people get away with it because the victim has no advocates. I have participated in these assaults.

OP- if your question is why we work futile codes, or codes in which "success" is a negative outcome for the patient: That is the system we work in. Do your best, and consider it practice for the occasional code in which you save a live and they and they live happily ever after. That is pretty cool. You will like it.

Living sills are not valid legal documents, so what the health care proxy says goes. If you don't have a healthcare proxy, next of kin wins. It's important to pick a healthcare proxy that knows your wishes and will respect them and to make sure that copies of the healthcare proxy paperwork are abundant.

HeySis, BSN, RN

435 Posts

Specializes in PACU.
So I looked up the statistics of surviving a code and they are less than 20% depending on what website I looked at. Now I feel like what is the point of running when they call a code. Any suggestions? I am trying to figure out what my mind set should be then next time I go to a code.

The survival rates use to be a lot lower. The first time I became ACLS, they told us one in ten survive to go on and live a meaningful life.

I was told then, and it has always stuck in my mind, that we do all ten so we can practice. Does that seem cold hearted? It wasn't meant that way. Any skill that you want to be effective at needs to be practiced, as anyone on a code team can tell you, some run better then others.

A team that runs a code on someone that does not survive still has served a purpose.

1. It has made that team more efficient.

2. Has given them a chance to see what they could do better next time.

3. Given experience to the newest members of a code team.

4. Lead to changes in code alga rhythms, as we get more data... which has lead to an increased survival rate.

5. May give family closure to know that everything that could be done was.

I am sure there are more, but practicing on the dummies, even the "smart, computer" ones, does not prepare you for what to do and how it's going to "feel" when the code is real.

Specializes in Critical care, Trauma.

The most important conversation re: codes needs to happen long before the code takes place, and it needs to happen repeatedly at changes of life and health status.

When I was 20 and completely new to the healthcare field (not even a CNA) I was helping to take care of a woman who, while only in her mid 60s, had been suffering with MS since her late teens. She had required a feeding tube for several years, and had a laundry list of other medical diagnoses that effected her daily life. Eventually her condition declined to the point where she needed to enter LTC and they had the conversation with her husband about a DNR. He came back to me and our conversation was to the effect of, "they are suggesting that they not even try? Why not even one round?". Our only exposure to codes were the ones we saw on TV, where no one breaks ribs and people either just bounce back to 100%, or they pass. Given those expectations...who WOULDN'T want their loved on to get resuscitated? What would there be to lose? Obviously now I see the error of that thinking, because of the training I went on to receive, but it makes no difference to her status at the time.

These conversations are so important to have with medical personnel that take the time to explain the real consequences of codes. It can't just be the quick, check-the-box, "If your heart stops, do you want to die? Oh, okay, moving right along..." conversation. And while we're at it, let's also talk about naming DPOAs that are both equipped and willing to carry the responsibility (have had several cases recently where the newly-named "decision maker" -- not even a legal DPOA -- has dementia, has "too much going on," etc) and that have a firm understanding of what is an acceptable quality of life is for the patient, cannot be overlooked. After mom has the massive stroke and is no longer able to communicate, it's too late to ask if she would want to have a feeding tube and 24/7 care for the rest of her non-speaking life in order to continue living, and families without previously-understood direction often have an incredibly hard time (understandably) making these decisions.

As a nursing student, it's great that you're learning about this now so that you can advocate for this in your practice.

Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

1) if you are not a DNR and have no signs of prolonged death (lividity, rigor mortis, significant trauma and presenting in traumatic cardiac arrest etc) we are obligated to start resuscitation, no matter your age or quality of life.

2) I have only had two patients survive to discharge with an intact brain after pre-hospital cardiac arrest in my 19 years in EMS. One was 22 and the other was in his 60s, both had wives, girlfriends, kids, parents, siblings, and maybe even grandkids to return too, and the potential for decades more to spend with those loved ones, making the other 498 that didn't survive worth taking the chance on.

3) Consider the 80% practice, so that 20% will live as we become more proficient.

4) Do you play the lottery? you should because there is a small chance you may win, there is a bigger chance you may loose, but you still play because even a small chance of becoming rich is worth the risk and effort. Consider cardiac arrest resuscitation as playing the lottery, except the prize is far better in that someone may win a second chance at life and a family wins more time with their loved one. The gamble is that sometimes you loose, but you cannot predict that.

5) We cannot truly predict who will live and who will die, or how long they may hang on, or whether their brain will be intact, thus we cannot pick and choose who we resuscitate (the exception is rule #1) .

6) As a healthcare provider you may secretly wish you don't get that 80 or 90 year old back because you know the chance of them ever coming off a vent and walking out the hospital is just about zero, and the only thing that is gained is a body that is traumatized, more suffering if you get them back even if it's brief, and a family who gets their grief prolonged, and lets not forget the financial burden, but you do it because you have too (see #1).

7) You will loose more than you save, but those two people I spoke of in #2 are real. The 22 year old went into cardiac arrest while at work after drinking numerous energy drinks throughout the morning, which put him in V-Fib arrest. We shocked him 3-4 times, gave him epi, Amiodarone, intubated him, and 30 minutes of CPR all on the side of the road, before putting him in the ambulance after ROSC was obtained. In our ambulance he was unresponsive with posturing so I really didn't think he would walk out of the hospital, but after several days of induced hypothermia he woke up neurologically intact. He now has a normal life and is healthy, and with the exception of his implantable defibrillator he is like any other 24 year old ( this was two years ago). I have never met him, but I knew his name of course so I "checked" on him on FB and I see the value our work and cannot imagine not attempting to resuscitate in appropriate cases, as I see him going to a baseball game with his GF or spending the day with his family.

To answer your question, you are running for the 100% of cardiac arrests that occur on your watch, since you cannot predict who will be part of the 8% of cardiac arrest patients who do survive to discharge and go home will be.

Annie

Specializes in Critical Care.
We do it for that small percentage of patients who come back and thank us later.

I bought my husband a coffee mug with a quote that says "To the world you may be one person, but to one person you may be the world." I look at every code from the perspective that while it's just another patient to us, that patient might be someone's whole world. To give someone the gift of more time with their loved one is a precious thing. Quality time, that is; I agree that sometimes we code someone because their family cannot yet let go, though they probably should.

I think you said it best!

Editorial Team / Moderator

Lunah, MSN, RN

14 Articles; 13,766 Posts

Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
Sincerely, without discounting anyone's personal experiences (and I've been through a terrifying situation with my own child) - may I ask why this discussion must become about "why bother" rather than the fact that this is an issue that emcompasses all four of the basic medical-ethical principles?

You know we get jaded — sometimes we go through the motions knowing there is no hope, and it gets discouraging. This is not to say that people lack ethics, just that our emotions take a beating over time as we try to fight death over and over again. I apologize if you felt that my post derailed the discussion. My posting style is rather abbreviated these days with the baby and adjusting to cardiac meds. Where did my energy go? Lol. Out the window with my sleep!

Susie2310

2,121 Posts

3) Consider the 80% practice, so that 20% will live as we become more proficient.

To answer your question, you are running for the 100% of cardiac arrests that occur on your watch, since you cannot predict who will be part of the 8% of cardiac arrest patients who do survive to discharge and go home will be.

Annie

Updated statistics on cardiac arrest survival from the American Heart Association show that for 2016 the survival rate to hospital discharge for OUT OF HOSPITAL cardiac arrest was 12% overall. For 2016 the in hospital survival rate to hospital discharge was 24.8%.

The statistics you provided are factually incorrect, and you are ignoring current evidence (which is a good deal better than you stated) when you tell the OP that he/she is running for the 100% of cardiac arrests that occur on his/her watch since he/she can't predict who will be part of the 8% of cardiac arrest patients who survive to discharge.

Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.
The difficulty I have with this post is that the poster is speaking from his/her point of view, which is fine, except their post doesn't include or allow for the patient's point of view. >80 year old patients even with multiple co-morbidities and what appears to other people to be little quality of life may indeed feel they have a high quality of life and wish to continue living. They may have many reasons to wish to continue living.

I've actually been on both sides of this issue. I was the legal guardian for my FIL fifteen years ago. He was essentially quadriplegic after suffering a brain aneurysm back in the 1980s and subsequent deterioration.

Initially, Dad was afraid of dying and wanted everything done. By 2003, he had come to terms with his mortality and told me he was ready to die. He had frequent UTIs due to a suprapubic catheter, and after he made his decision, we allowed him to succumb to the next infection.

The thing is, we had the difficult conversation. Too many people are unwilling to do that. I let my husband, brother-in-law, and sister-in-law know about it when Dad made his decision, but I didn't ask their opinion on the matter, because this was between Dad and me, as his guardian.

All of that happened before I even knew I wanted to become a nurse. I had no experience in healthcare. I had never witnessed a code before. But as a human being, I knew that it was important to have the difficult conversation and ascertain what the patient did and did not want done with their life.

If I had been in my FIL's position, I would have opted out a long time before he did -- I personally just don't want to live the way he had to live. But it wasn't about me, it was about him. I supported him while he chose to continue fighting, and I supported him when he was ready to give up.

The day after my son turns 18, I'll have a new advance directive written up naming my son as my Patient Advocate. He and I have discussed End of Life Care extensively through the years, and I feel confident knowing that he will be willing and able to respect my wishes when that time comes, because we have had those difficult conversations. I only wish more people would be brave enough to do the same.

HermioneG, BSN, RN

1 Article; 168 Posts

Specializes in Emergency Nursing.

In my very limited experience, I also think that we code the patient to see if there's any reversible causes that might be causing the patient's condition. The H's and T's come to mind here. Statistically speaking, yes, a lot of the time the patient is not going to survive. But unless the patient states otherwise (DNR) I think they deserve a fighting chance and for us to investigate further and try to bring them back and/or identify any reversible causes.

Also (and I'm not saying anyone is doing this) but I don't think age should be an initial factor when deciding on if we should code a patient or not. I've personally seen two elderly gentlemen who obtained spontaneous ROSC (one in the field, one in the hospital). The one who was administered CPR out in the field came into the ER chatty and joking and all around in great spirits. It was incredible.

At my old job (lifeguard at a pool) we had two full arrests where the person survived. One of them (a little old man with a walker) came and talked to us at our inservice the following year. He thanked us for saving his life and talked about being able to spend more time with his grandchildren and his family. For that 20%, it is quite literally everything.

Also, on a personal note, someone very special to me had a full arrest out in the field. He was getting into his car at the gas station, started his car and locked his doors, and arrested right there. A bystander had to break his window and drag him out to start CPR. He's in his upper 70s and has advanced heart disease, and if someone was to simply read about him clinically they might also ask "why are we coding this patient?" but in reality he lives a full and vibrant life and is loved and treasured.

Thankfully they brought him back and saved one of the greatest men that I know. So its my personal belief that we code everyone (unless patient wishes are expressed not to through a DNR) because everyone deserves a chance. And because we can sometimes bring them back and give that person and their loved ones more precious time together.

suzil

98 Posts

Specializes in All areas of Critical Care, ED, PACU, Pre-Op, BH,.

However, it is not ever our job to be God. We don't decide not to Code someone unless they have a for certain DNR. We do what is right for all.

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