Why do we do codes?

Nurses General Nursing

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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.

Specializes in Critical care.
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.

Can you say slow code?

;-)

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1. Anyone have a crystal ball? How do you know who will and won't survive?

2. We as humans will talk about everything but death/dying.

3. How many nurses have a DNR or POLST? Do we talk to our patients about what those forms are?

4. How many doctors, NPs or PAs talk to their patients about DNR or POLST? Is it charted in the notes? Did they write an order? Who knows?

5. How many people have talked to their families about being an organ donor? Do they have it on their drivers license?

6. How many people have completed an advance directives like a DPOA (Durable Power of Attorney)? Have you?

7. Has anyone made funeral arrangements? Know whether they want cremation or burial or where's my final resting place?

8. Will I donate my corpse to science so others can learn like we did?

Medically we do what keeps the facility out of legal issues and serves the families emotional needs.

Unwanted codes could be avoided if:

Patients would talk to family;

Patients and families would talk to care providers;

Care providers would become more comfortable talking about death/dying and DNR/POLST/DPOA forms and encourage completion; and

If all of us would complete forms and accessibly store in home where someone knows the location; online State databases with facility access and/or facility have on file for admission.

Something to think about.

Maybe we should practice what we preach...

Or think about preaching?

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Can you say slow code?

;-)

I do not know of anywhere where a slow code is the legal standard of care, and I would think it would have a high chance of being found out and brought to legal scrutiny (think: patient's family members attorneys), as well as being highly unethical. If the patient/family/decision maker have stated their wish that the patient is a Full Code, they have the legal and ethical right to trust that their decision is carried out according to the standard of care. The standard of care for BLS and ACLS is not that they are performed slowly with the intent to avoid successful resuscitation and ROSC; on the contrary, they are performed as expeditiously as possible with the aim of achieving ROSC.

As I see it, anyone participating in a slow code would be practicing below the standard of care and would be committing malpractice. I would presume the medical record would be falsified too as no nurse/physician would want to document untimely responses during a code - the recorder would be recording the times the interventions that took place during a code, from the time the patient was found unresponsive, the time compressions were started, the time the Code call went out, the times the patient was shocked, and the times medications were administered, along with the times any other interventions took place. How would you expect these times to be recorded during a slow code? A lot of professional liability for anyone who participates in such a practice, in my opinion, and the mere mention of this practice does nothing to encourage patients and family members to trust nursing/medical professionals regarding resuscitation/end of life decisions, and in my opinion explains some of their reluctance to do so.

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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.

If the living will is properly notarized and witnessed according to a given state's requirements, it is indeed a "valid legal document."

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Specializes in All areas of Critical Care, ED, PACU, Pre-Op, BH,.
Can you say slow code?

;-)

No, we cannot.

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Specializes in Emergency Nursing.
Can you say slow code?

;-)

Woah... what the?

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Specializes in Informatics.

So you can look the families of your patients in the eyes and say:

"We did everything we could"

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Specializes in Med/surg/ortho.

Although 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%.

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Oh 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.

Best,

Gary

(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)

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Specializes in Oncology.
If the living will is properly notarized and witnessed according to a given state's requirements, it is indeed a "valid legal document."

I guess I didn't realize how much they were state dependent.

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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.

I think that we need to remember that the term discharge” does not mean discharged back to home, fully functioning, baking muffins for the grandkids.”

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.

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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.

Your 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.

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.

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