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.

I 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.

In 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.

Specializes in Critical Care.

There 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.

Specializes in Rodeo Nursing (Neuro).

The 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.)

I think a big part of it is because people are afraid to face the fact that they may get sick and die...

And because they have no IDEA what a code actually puts a patient through...

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!!!” ...

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....

The end of life care conversations need to happen, with education, early.

(The ellipses were inserted by me as I cut out large portions of text in the quoted post above-easier than inserting 5 individual quotes from the same post!)

A close relative of mine was recently admitted to the hospital for the first time in 60 years (since childbirth) at the age of 87. She was in obs status after what was very strongly suspected vasovagal or orthostatic near-syncope. Normal labs/vitals/exam other than mild initial hypotension that corrected after a liter bolus. Lives independently, alone, drives. No meds.

She worked as a cook in a nursing home for years and that was her only exposure to medicine. She saw people with trachs and pegs and it left her vehemently opposed to anything like that for herself and her family. She has had a living will since before I was born and has told me (her POA) along with every relative we have about her wishes (No Trach! lol. Basically allow natural death...DNR/DNI)

Imagine my surprise when she called me in a panic because her admitting MD asked for code status and she couldn't decide! She said she didn't feel ready to die. I wasnt sure what to say so just started talking about what CPR is, the chance of success and what recovery would entail if successful. She had no idea that post code she would be in ICU and intubated at least for a short time (she thought she might wake up and be fine and go home the same day like TV).

When I mentioned she might have ribs broken and severe musculoskeletal pain she recalled having broken ribs and bad contusions from a MVA and how difficult and painful her recovery was. She immediately decided to be DNR and had no anxiety or doubts.

Turns out her doctor did what I've seen a million times: "Now, ma'am, we have to ask this question of everyone...you are very stable, but heaven forbid if the worst happens-and it won't happen-but if your heart stops or you stop breathing, and you are dying, do you want us to do everything we can to save your life?" A lot of patients respond with "I'm not ready to die." They don't realize that we're talking about a situation where their body IS ready and is in fact dead.

Some say things like "well, if I have a chance of full recovery then yes but if not let me go." These are patients who I believe should be told what the outcomes data shows, what CPR actually is and what the recovery process involves etc. Instead i hear the doc say "ok then, we will do everything we can. Now, what have your bowel movements looked like?" Patients should be making these decisions based on accurate info. It also needs to be clear that code status addresses treatment for code situations only-it has nothing to do with how aggressively we treat anything else. My aunt didn't realize that; like many patients she thought they were basically asking if she wanted curative treatment or hospice!. Plus, the question was posed in an emotional vague way-"do you want us to do everything to save your life?" rather than "do you want chest compressions and a breathing tube and ventilator if you stop breathing and your heart isn't beating?"

My aunt is the absolute last person I ever would have expected to be full code but she was for a few hours because of the way her doctor communicated (or didn't). I see the same conversations happen with my patients all the time. I want to educate but it's hard, as the nurse and not knowing my patients wishes like i know my aunt's, to go in after the doc leaves and say "hey, when you told him to do everything to save you, did you realize he was talking about CPR and breathing tubes and nothing else?"

There is also the issue of some nurses not understanding that DNR aka "Do Not Resuscitate" does not mean "Do not treat." A problem arises when physicians and nurses lack knowledge that care - assessment, diagnosis, and treatment, should still be provided under a DNR, and that DNR just means "Do Not Resuscitate" if the patient's heart stops and the patient is in cardiac arrest.

I remember a discussion on this forum where a poster mentioned that their family member who had DNR status was refused treatment by the doctors/nurses, and the poster had to go up the hospital chain of command to make this happen. Fortunately this poster was a nurse, and knew how to do this, and was able to be effective, but this was obviously a very stressful situation for him/her and his/her sick family member. The general public without medical/nursing training would find this situation even more difficult.

I have read other posts where people have expressed their lack of understanding of how they should treat patients who have a DNR. This type of situation also brings up questions about prioritization of care when a nurse has a number of patients, with, for example, some who are a Full Code and some who are a DNR, and I think accounts for some of the general public's ill ease on this topic.

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