No code changed to Full code

[yooperPN]

Hi! The last couple days at work have been extremely stressful. I work midnights for LTC and we've had an actively dying 80+ yr old who's code status changed a couple months ago from no code to full code. I've heard there was a recent law that passed changing a lot of resident's code statuses, and another nurse explained to me it was because the resident had a guardian, not a DPOA.

This resident has been deteriorating over the past couple of months, refusing meals and medications. He is probably a little over 80 lbs. The other night at work, he went into unresponsive status and began the actively dying process. His physician and family knew and were in agreement, do not preform CPR. His physician left his cell phone number behind in the event he passes, so we can get him pronounced immediately. This same physician who doesn't like on-call doctors treating his patients explained for us to not only have a nurse calling his cell number, but to have us page the on-call at the same time so SOMEONE would pronounce him immediately.

So, I arrive to work the other night with all of this going on and I'm stressing out. I go in his room to check his status and his family is at bedside. They leave the room so the CENA's can do their cares, and one of the family members lets me know that she will throw herself across his body if I attempt to preform CPR on him. I tell her that it wont get to that point, I have the Dr.'s cell number at hand and will be calling the on-call Dr. if need be to avoid all of this. I, out of courtesy, let all the other nurses in our facility know the situation so they can be prepared if I called a code. Luckily, I didn't have to the first night.

The next morning I explain the situation going on to the charge nurse (his status changed after she left work that day so she wasn't aware he was actively dying). I tell her about the CPR situation with the family, and my agreement I had with them knowing that technically I couldn't do that. She didn't come out and say I was in the wrong, but did say that if he goes that day when she's there they have to initiate CPR while others are trying to get him pronounced. I warn her about the family and their statements and hope it doesn't have to go to that point. That night I'm scheduled to work and find out he's still with us, but in worse conditions then he was the first night. Of course, it's time change night so my usual 8 hr shift is 9 hrs and I'm figuring he's probably going to go on my shift. Same family members are at bedside and this time they seem relieved I'm there because I said the night before I wouldn't perform CPR. So, I again make my courtesy calls to the other nurses in the facility.

Later in the night, one of the other nurses comes down to my floor and chit chats with me on the situation. She asks me what my charge nurse said about the CPR thing, and I explained she didn't necessarily tell me I had to do CPR, but told me she would do it if he passes while she's there. This nurse then asks me if it's against the law to not initiate CPR on a full code Resident. Immediately I think, uh oh... here we go. I tell her my plan is that if he passes, I have the CENA's calling the code while I'm calling the Dr. because I do not see the point in battling in the room with the family about doing CPR. She then states, "I don't know if I'd risk my license doing that." So, the rest of my night was spent in his room every 30 minutes checking vitals to see if he's beginning to go downhill more so then he already was. He didn't pass on my shift and I've been off the last couple of nights, so I don't know if he passed yet and how they handled the situation.

My question is, I know technically what we're suppose to do with full codes, etc. But, what would you really do if you were in my shoes? Would you really go through the dramatics and the trauma to the family to begin CPR on a resident that you know isn't going to come back from it, and you're only injuring the body more. Was I in the wrong by saying I wouldn't initiate CPR and would call the Dr. first? Ethical dilemmas are not fun!

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

Have you read the American Heart guidelines about initiating CPR in hopeless situations?

[nurse_autumn]

Is one of the family members POA? I don't understand if they feel that strongly about it why they wouldn't sign new code papers? Personally, I would initiate CPR while another nurse was contacting the MD. Having a full code signed by the doc is a legal document and if you withhold CPR.....weelll, not a choice I would make. It would definitely be a priority in my facility to get the POA and MD to sign a DNR

[yooperPN]

Haven't read that article, going to look it up! Thanks!

The resident has no POA, DPOA, or however you want to word it. He has a guardian and a person in charge of finances. Apparently, from what I understand, there was a law passed recently (not sure if it's state or federal) that in order for you to have a no code status you or your DPOA has to make those decisions. Prior to this law, guardians could also make those changes. Since he's been in rough shape for the past couple of months, he or his family has been in no shape to get to the courthouse to get those papers signed. So, instead, our facility had to update his code status and had him/his guardian sign the new status.

I guess I am thankful that he didn't code on me. But then again I'm having mixed feelings because I don't know how the family reacted if he did code on someone else.

[ObtundedRN, BSN, RN]

I don't know if I entirely understand. But once the patient is unresponsive and unable to make his own decisions, the next of kin would be the legal authority. If the family is there, is one of them not the legal next of kin?

[yooperPN]

I don't know if I entirely understand. But once the patient is unresponsive and unable to make his own decisions, the next of kin would be the legal authority. If the family is there, is one of them not the legal next of kin?

Is that actually the case? Or, is it that you need court documents deeming him unable to make his own decisions? His wife passed away years ago, but he has living children that were all at his bedside the night I thought he was going to go. Each and every one of them did not want CPR performed because they knew that not only was it more traumatic for him/his body, it wasn't going to bring him back.

[Zen123]

If this resident has been declining and the md did not want him sent out to the hospital...and the md and family is aware and in agreement with the plan of care..then all you can do is provide comfort care and make sure you document.

[yooperPN]

Zen123, his declining status is a whole other issue.. I picked up on something going on with him a few months back. He's diagnosed with hematuria and neurogenic bladder. He's had a permanent catheter since he's been with us, changing it out once a month. He's had blood (and I mean red) urine for as long as I can remember, but the MD wasn't keeping up on doing CBC's with him. A few months ago, he had 3 falls in a 2 week period, one of them involving him being behind a closed door on the floor sleeping with chair alarm sounding off. That night I called the MD because it was obvious something was changing with him, and changing drastically.

MD came in the next morning, didn't think anything was wrong, noted the blood and clots in the cath bag, but that was it. 10 days later he finally ordered a CBC, and his hemoglobin was 9.3 or something like that. His orders were for us to monitor for changes.... WHAT?! (I secretly wanted to yell "What do you think I called you for in the first place?!") That was infuriating, but then I thought maybe it was family wishes. So, since nothing was really done about the low blood count, he's just gotten weaker and weaker.

But, because he didn't have a terminal diagnosis, he wouldn't qualify for hospice (which the family wanted also). So, comfort care wasn't really something, as far as I know, that we could legally do.

[RescueNinja]

I'm curious as to why the MD did not write an order for no resuscitation?? Maybe it is different in the US, but here they can (and do) write DNR orders in situations like this.

[FLArn]

If a patient is declining to the point where his life expectancy is less than 6 months they most certainly ARE hospice appropriate. They don't have to have cancer, etc. Multiple comorbidities are listed as debility as an end stage diagnosis. The actual "death certificate" diagnosis is "multiple diseases of the elderly" (also known as old age or natural causes in the old days)

[Zen123]

Something"s missing here. Moving on. :)

[LoveMyBugs, BSN, CNA, RN]

I am still confused reading all your posts. The patient has a guardian is that correct? Then why not get the guardian to sign the DNR orders.

If the MD is aware of the decling status then why hasn't he signed DNR/POLST orders yet?

If he is having changes in condition, and is a full code (even though you describe it as dying) he is a full code and having changes in conidtion and would need to be addressed.

Also you do not have to have a terminal DX for hospice. Life expectancy of less than 6 months, allowing you to make them as comfortable as possible.

I just had a woman in my facility who had no terminal dx, but basically lost her will to live, her daughter commited suicide and she (my patient) lived for 5 days with the body before she got help. She had dementia in her lucid times she would mourn her daughter. Such a sad case, broke all of the staffs hearts she was with us for about 3 months, essentially her depression is what killed her, she stoped eating and had deteroiated so bad that she was on hospice less than 24 hours before she passed. No termial dx.

Sorry back to your patient.

IF the family is that adimit about not having CPR done then they need to get it in writting somewhere.

I have had to CPR on people I didn't want to where every part of my being screamed this is wrong, but the code status was a full code.

What I don't understand is the MD is aware and hasn't changed the code status