Why do we do codes? - page 4
I'm a nursing student and recently experienced my first code. I felt like I was the only person in the room that had any hope that this lady would make it (granted she was 80 years old) and... Read More
Sep 9, '17Quote from blondy2061hIf the living will is properly notarized and witnessed according to a given state's requirements, it is indeed a "valid legal document."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.
Sep 9, '17Quote from hawaiicarlNo, we cannot.Can you say slow code?
Sep 9, '17Quote from hawaiicarlWoah... what the?Can you say slow code?
Sep 9, '17So you can look the families of your patients in the eyes and say:
"We did everything we could"
Sep 9, '17Although the chances of getting someone back are slim there's still that chance. We do it because we must, but we also do it for that 20%.
Sep 9, '17Oh boy, how to answer this. I'll keep it short.
Don't let numbers mislead you and keep you from giving 100% during an RRT or code. My hospital has pretty good success rates with codes.
We RUN to a code because every second matters. That is the mindset you must have. Maybe no one capable to at least do compressions is in the room (did a smart family member or visitor push the code button because their loved one just went into cardiac arrest?)
We run a code because the pt is a full or partial code status. Maybe they shouldn't be, but for now they are and you work the code like hell until a doc calls it. If you feel weird about coding a person who in your mind should have been a DNR status then you learned an important lesson about the importance of a crucial conversation with your pt and their loved ones about code status (get the MD's and ethics folks involved)
We work codes to their endpoint to help perfect our response, critical thinking, and teamwork not only in that moment but for all the future codes you will be a part of. This is no simulation. Learn something from every code, debrief every code, and carry that knowledge with you to help others.
You never know when you will need to do CPR (my RN friend had a bicyclist drop dead right in front of her as she was leaving a gas station. She did high quality CPR on him until the medics arrived. Another RN friend ran a "code" when a fellow passenger had a cardiac arrest on an airplane). You just never know.
Feel free to pm me if you want to discuss this more.
(ps, I'm a member of my hospital's RRT/Code Blue Evaluation Committee. Maybe you should look into your own hospital's eval group. It's really very interesting)
Sep 9, '17Quote from HorseshoeI guess I didn't realize how much they were state dependent.If the living will is properly notarized and witnessed according to a given state's requirements, it is indeed a "valid legal document."
Sep 9, '17Quote from Susie2310I think that we need to remember that the term “discharge” does not mean “discharged back to home, fully functioning, baking muffins for the grandkids.”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.
Discharged simply means discharged from the hospital, and it often also means that the patient was trached, pegged, PICC’d, and sent to LTAC or a Skilled Nursing facility where they will live a few more weeks or months.
My problem with the mindset of coding everyone just for that small chance that they “make it” is how we define “make it.” Once a patient has been coded and has achieved ROSC, I find it becomes incredibly hard for the family to re-center and make rational decisions based on the patient’s previously known wishes/best interest.
They are of the mind that Grandma made it through the code, (“she is a fighter!”), so she must want to, and have the capability of, fighting through all that comes after coding. Then comes an escalating chain of decisions to intervene and the family feels like they can’t turn back because they and Grandma have invested so much, even though Grandma is fed through a tube, can’t talk to or recognize anyone, breathes through a hole in her throat…etc.
Too many times, we resuscitate people only to give them a miserable, suffering few weeks or months before they ultimately die.
Sep 10, '17Quote from scrubs0204Your mind set should be that you give it the best you can. I don't think it's uncommon to want to look at a situation "logically" or "rationally", but I think you have to remember that, at work (or school), you are providing care based on decisions of others. Presumably, the things we do are aligned with our patient’s wishes. Alternatively, the things we do are aligned with the wishes of the patient’s power of attorney or other designee. Sometimes we’re lucky and patients have appropriately completed advance directives giving us guidance. Alternatively, sometimes decisions are made due to an emergent situation in the absence of being able to discuss with or contact the patient/family/power of attorney.I'm a nursing student and recently experienced my first code. I felt like I was the only person in the room that had any hope that this lady would make it (granted she was 80 years old) and thankfully she did. We Life Flighted her and she died at the facility that we sent her to. 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 last part is the part that really is unsettling. In my practice are (OR), we deal with emergency situations all the time. I work in a level 1 trauma center, so with some frequency we have patients arrive whom we don’t even know their name. They’re assigned a fake name, receiving any and all medical interventions designed to keep them alive. They’ll have a procedure (often procedures and with some frequency concurrently) designed to “fix” their problem. We’ll intubate them, code them as many times as they need it, get central access, place every monitor and type of drain known to man. They’ll be on massive transfusion protocol, put in a coma, put on ECMO, put on CRRT – you name it. If we can do it, we will in the absence of a patient representative to assume the responsibility of decision-making. Sometimes it works, others it does not.
But then we’re stuck defining “works”. What does works mean? People have different definitions of “life”, “quality of life” a “meaningful life”, etc. There are clinical definitions for death – centered on cardiac or neurologic function (or absence). I struggled for a long time, knowing many patients would not return to their baseline following their trauma, emergency procedure, etc. It was incredibly disenchanting – knowing that days all I did was care for patients having emergency procedures and they all either died or had other “bad” (as defined by healthcare staff) outcomes. Eventually, I accepted that my helping the patients have a chance, or helping meet their wishes (or the wishes of their decision maker) had to mean something.
The reason we do these things, exhaust everything possible are the outliers. The ones who there is no explanation for how well they’re doing but they are doing so well. You remember those folks. They make it all worth it. Seeing that kind of outcome makes all the effort exerted seem more worthwhile.
Sep 12, '17I work in the OR and have witnessed a surgeon in his 30s got a heart attack during a case. He had to be shocked more than a handful of times, but he made it.
Sep 20, '17In our area, we have "Goals of Care". Ideally this is to be discussed with EVERY patient who enters hospital. In Goals of Care, patients can choose from 3 levels of resuscitative care (chest compressions; intubation and meds; or meds only), 3 levels of medical care (no code but treat active medical problems and may do surgery with some levels), and 2 levels of comfort care (C1 is treat symptoms and C2 is for patients who are literally expected to pass within the next couple of days). This way it's not a blanket "DNR".
I have already told my husband that I ONLY want a code called for me if it's a witnessed arrest. I have seen patients with iatrogenic brain injuries from codes and I don't want to live that way. If no one knows how long I've been gone, just let me go.
Sep 20, '17There are a lot of good answers in some of the responses I read. Its true, we code people because of the 20% who might make it. We code people because they or their families have stated they want to be a full code.
But, I think a big part of it is because people are afraid to face the fact that they may get sick and die. People are afraid it talk to their family members about what care they do or don’t want when they can’t make their own decisions. People can’t or won’t accept that there may be a day when they can’t make their own decisions.
And because they have no IDEA what a code actually puts a patient through.
I’ve seen a family put thier incredibly ill 80 something year old family member through code after code after code after code. Why? Because the patient once said he’d like to live to 102.
I had a 90+ year old patient and I was discussing code status with his 70s year old children. They stated he was a full code. During our conversation I stated that during cpr we do a 2 inch compression that will break his ribs. His daughter said “It doesn’t look that way on TV!!!” I told her they can’t do CPR on someone for real on tv because they would break someones ribs.
Also there are a lot of family members that feel that if they make that DNR decision that they will feel guilty because they feel like its giving up hope. Or that in signing that DNR it makes them feel like THEY’RE the one “killing” the patient instead of the disease process. I’ve had family members tell me they are making their family full code because they’re good Christians and want to do everything possible.
The end of life care conversations need to happen, with education, early. I think its an important education and discussion process that every healthcare employee should be trained in (as patients and family members may be intimidated or afraid to ask doctors). Clearly I’m a firm advocate for DNR/DNI/ Comfort measure education and processes, but I guarantee I’ve worked just as hard to get back patients I knew wouldn’t make it because thats what they want.
As a nurse you have to examine your feeling, but sometimes you may need to move past that to do what the patient wants. Good luck in your studies.
Sep 20, '17The various sides of "why bother" having been pretty well covered, may I say that the first time I witnessed a code, it was pretty interesting, but as a UAP (unlicensed assistive person) I was hardly more than a looky-loo. The first time it was my patient who coded was a life-altering experience, although one of the biggest shocks to me was how very little the primary nurse does, once the code is called. The next couple of days put me through a wringer, and more than a decade later, I still can't say with complete confidence that that man wouldn't still be alive if he had had a better nurse (nurses I trust who were better nurses told me not, and I have to believe them, but...) Biggest lesson I took from that--if you're wondering whether to call a code, call it now. My second code was a "false alarm", but only because we found the problem and fixed it seconds before the Code Team arrived (and not one member of the code team called me a dumb ass, in case you wondered).
I've been through a couple of pretty brutal no-codes, too. Worst, no doubt, was when my Dad passed, at home, on hospice. As I caressed his chest in a loving goodbye and located his xyphoid process, two parts of my brain were at WAR. I did the right thing and honored his wishes, but it was hard, hard, hard, and a few years later when I spoke to my cousin, herself a retired nurse of many years experience who was (thank God!) there with us, she said she had read my mind as it happened, that I did make the right choice, and that if I had made the wrong choice, she would have jumped right in there with me, because it was just as hard for her.
And then there was a patient, one night, with a clear DNR order, dying of the kind of stroke you don't want to survive. Her more typical outcome would have been to pass months later in a nursing home, but that night her condition began to deteriorate and I paged the resident, just to let him no what was happening. To my surprise, he and his intern came up and stayed a couple of hours as she passed, alone except for the three of us. To this day I don't know why the docs came. Maybe, like me, he didn't want her to die alone. Maybe it was a learning experience for the intern. Maybe something in my calm, professional, and really quite manly page told him how sad and helpless I was feeling. In any case, I was extremely grateful for their help not doing a damned thing--because it was right and it was hard.
Since then, I've been a participant in three codes in which I performed my role as the patient impeccably. Yep, I'm one of the 20%, and grateful to those who saved me. But here's a thought about that: like another controversial procedure--circumcision--it probably was painful, but I did live through it, and I don't remember a thing about it. Whatever suffering there may have been was brief and long forgotten, but the benefits (minor or major) will be with me the rest of my life. As it happens, I was well past the age to think of starting a family before I ever placed a Foley for an uncircumcised man,but if I were to have a son, he'd be circumcised. And my code status is Full Code (but that could well change, down the road.)