The Slow Code - page 10

by TheCommuter 26,623 Views | 148 Comments Senior Moderator

I have been a nurse for only seven years; however, certain events and situations will remain embedded in my memory for the rest of my life. One of these events took place during my first year of nursing practice when I was... Read More


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    in the hospital where I do my clinicals the nursing supervisor can pronounce, and just has to call the doc to notify...
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    Quote from NursieNurseLPN
    This is a little off topic, but ive also seen- RN may pronounce. So in that case, if theyre a full code, you'd perform until the rn called it, right? No ems, physician needed at that time?
    Or is it only with a DNR that it would say RN may pronounce? Im sorry, im starting in a ltc facility this week so i thought id ask. Please feel free to correct me if im wrong! Thanks!!
    This is dependent upon the state.

    I work in Texas, where the scope of practice allows one RN to pronounce death. However, individual facility policies and procedures might call for two RNs to pronounce, or for EMS personnel to pronounce, or for a physician to pronounce. However, RNs are allowed to pronounce death in the state where I live.
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    Quote from lemur00
    Yeah the ones whose families want us to do everything while they pray every day that God will "take me home". Painful. Not entirely convinced that a slow code is a terrible ethical violation in those cases.

    Our health region is moving away from the language of DNR altogether. We now go through advanced orders as part of the admitting process (if we can get them to do it) with patients in essence writing their own orders. There are sections pertaining to CPR, treatments, antibiotics, and nutrition specifically. They are also encouraged to designate a proxy. This paperwork follows them wherever they go in the region and can be changed at any time they want. We've gone this route because of many of the problems brought up in this thread (living wills being in legalese and disregarded, lost because they are in a safety deposit box somewhere, Doctors who don't treat etc.)
    That's called a POLST here in California and likely elsewhere too. It goes through those points and follows the patient.

    As far as having a medical care proxy, I suppose that it could be written in the proxy language that the proxy may not make decisions concerning changing DNR status... that all other therapies may be done per the proxy's orders. In effect, a limited medical POA might be set up...
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    Quote from bbuerke
    How does that work? If someone stops breathing but has a pulse, unless you do something about it, eventually they will have no pulse. Are you supposed to just stand around and wait for the pulse to stop, then do compressions because they are not a "DNR" as well? I realize I'm being nit-picky, but this image just made me think of Peter Sellers in Murder By Death:

    "Not breathing. No pulse. If condition does not change, he'll be dead!"

    LOL!
    Seriously yes that's pretty much how it works. Crazy I know but MN is not exactly on the cutting edge of nursing practice.
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    Quote from TheCommuter
    This is dependent upon the state.I work in Texas, where the scope of practice allows one RN to pronounce death. However, individual facility policies and procedures might call for two RNs to pronounce, or forEMS personnel to pronounce, or for a physician to pronounce. However, RNs are allowed to pronounce death in the state where I live.
    I've always been confused by what officially constitutes "pronouncing". Where I work (skilled nursing in Michigan) if I discover a dead resident I chart "resident found without pulse or respirations", I then call the on call physician for release of body order and then do all my various other phone calls and paperwork. On the paper I give to the funeral worker who picks the body up I list time of death as the time I discovered the body. I've done this a dozen times and never once did a RN lay an eye on my resident nor was a RN even consulted by telephone. Did I "pronounce" in these situations? Did the physician "pronounce" with me as his proxy when I called him for release of body order? Are we doing things right?
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    Quote from TheCommuter
    This is dependent upon the state.

    I work in Texas, where the scope of practice allows one RN to pronounce death. However, individual facility policies and procedures might call for two RNs to pronounce, or for EMS personnel to pronounce, or for a physician to pronounce. However, RNs are allowed to pronounce death in the state where I live.
    Thank you!
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    That's called a POLST here in California and likely elsewhere too. It goes through those points and follows the patient.
    Yeah it's likely the same thing (pt orders for life sustaining tx? We call it my voice or MVLST).

    The protocol here is that the proxy usually only speaks for the patient if the patient's wishes aren't known. So if they have already filled out specific orders, we only go to the proxy if there's a situation that arises that wasn't covered by the forms or is ambiguous. If a proxy isn't chosen the closest living relative is automatically the proxy (and there's a list--for example the eldest child of a patient with no spouse will be the proxy, even if a younger child actually looks after the parent). That's the main reason we encourage the patients to designate someone of their choosing.
    Last edit by lemur00 on Dec 9, '12 : Reason: add quote
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    Quote from T-Bird78
    If there's no DNR then aren't we required to use any and all measures? Just because someone's older doesn't mean they don't get the same level of care and urgency as a child. They're somebody's parent, somebody's grandparent, somebody's spouse. It almost borders on criminal neglect.
    After seeing how many elderly and ill patients end up after we have 'done all that we could', I think that borders more on criminal neglect than coding a patient who does not have a chance. I believe that is more cruel to the patient and their family than letting them go. If they were a child, I would feel good about doing everything. If they are 89, unable to feed themselves, incontinent, confused and scared, skin and bones because they won't eat or drink, then I don't feel quite so good about doing everything I can. I would rather make them comfortable at the end of their life which is, after all, a natural thing that will happen to all of us.
    somenurse, PMFB-RN, and Anoetos like this.
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    You gave the physician the signs of death (pulseless, no rise & fall of chest noted, unresponsive), so the doctor is essentially pronouncing with you serving as the proxy.

    When I was an LVN, all I could chart was the signs of death (all pulses absent, no respirations noted, etc.) and that the doctor or RN pronounced death at 12:00. Now that I'm an RN, I can document that I pronounced death.

    However, certain states allow LPNs to pronounce death independently of a physician or RN. I believe that Oklahoma might be one of them, although I might be wrong.
    Quote from BrandonLPN
    I've always been confused by what officially constitutes "pronouncing". Where I work (skilled nursing in Michigan) if I discover a dead resident I chart "resident found without pulse or respirations", I then call the on call physician for release of body order and then do all my various other phone calls and paperwork. On the paper I give to the funeral worker who picks the body up I list time of death as the time I discovered the body. I've done this a dozen times and never once did a RN lay an eye on my resident nor was a RN even consulted by telephone. Did I "pronounce" in these situations? Did the physician "pronounce" with me as his proxy when I called him for release of body order? Are we doing things right?
    BrandonLPN likes this.
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    Quote from PMFB-RN
    OK I am going to disagree. A proper slow code is an art. How to make it look like you are doing something when not really trying to save the patient. As far as I am concerned the slow code will be needed as a self defence mechanisim for health care providers so long as our society maintains it's irrational refusal to talk openly about end of life issues and accept that dying is part of life. I am a full time rapid response nurse. I am the code administrator for my hospital and the alternate code team leader until / if the "code chief" (usually a senior med or surg resident) arrives on the scene. Occasionaly I will run the entire code like the few times there have been two codes going on at the same time or the code chief doesn't show up for some other reason. ON several occasions I have refused to code a patient at all. Other times I will let the team know this is going to be a a "show" or "slow" code. In every instance I had reason to know the patients wishes and knew that being coded was aginst their wishes. For example one man with severe necrotic bowel, literaly rotting from the inside out did not wish to be coded. When he was alert and oriented early in his hospitalization he made the informed decision to be a DNR. Later, when he could no longer make his wishes known, his estranged wife changed his code status to full code. The real problem is that she would be allowed to do that at all. That his weak kneeded-fearful-of-a-lawsuit physicians agreed to the change in his code status is another major problem that needs to be adressed. However all that is water under the bridge when "code blue" is called on him. If the patient has made an informed decision to be full code I will code the heck out of him. I will not go aginst a patient's informed decision and wishes. I hope it doesn't cost me my job (so far not an issue) but if i does it does.
    There is a difference of a true slow code and an unethical whatever you want o call that happened in the LTC facility.Like mentioned here I have slow coded before. It's not always these patients choice to be coded. Family members will keep the pt's alive for themselves when there is clearly nothing left to the the patient. Like the one that was unresponsive and literally ROTTiNG on a vent. He never had a say. He was slow coded.The woman who had pretty much. No limbs left, her skin was practically melting off, she was trying to pull out her teach constantly.... Her daughter would take her DNR on and off depending if she had an event coming up...... She was slow coded. For her sake when we gave her am care ( this was all in the ICU). We prayed when we turned her she would go.So, if it's an ethical issue, I feel by far more unethical pounding on one of the patients chests with all my might that giving them a full on code.And the MD's stood by all of these codes.
    BrandonLPN and PMFB-RN like this.


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