The Slow Code - page 11
by TheCommuter 25,882 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
- 1Dec 10, '12 by ♪♫ in my ♥Quote from redhead_NURSE98!Sometimes I wonder and sometimes I don't have to wonder because it's blatantly obvious... I've filled out my share of APS reports.Do you all ever wonder if these wishes are financially motivated? Like the deadbeat kids who "take care of" their parents in the parents' home, and cash their SS checks to "provide care" for them? I sometimes wonder when I meet these people.
- 0Quote from redhead_NURSE98!*** Sometimes no need to wonder, it's obvious. I have even heard family emebers say it/ Like the example I gave before abotu an estranged wife changing her husbands code status when he could no longer make his wishes known. He recieved a nice pension and she depended on it. "Even anouther couple months would make a difference" is what she said to one of our CNAs.Do you all ever wonder if these wishes are financially motivated? Like the deadbeat kids who "take care of" their parents in the parents' home, and cash their SS checks to "provide care" for them? I sometimes wonder when I meet these people.
- 1Dec 10, '12 by Esme12 Senior ModeratorQuote from redhead_NURSE98!Sometimes...I have always said...they either love them so much or they are paying them back for a bad childhood......or they need the money.Do you all ever wonder if these wishes are financially motivated? Like the deadbeat kids who "take care of" their parents in the parents' home, and cash their SS checks to "provide care" for them? I sometimes wonder when I meet these people.
- 4Dec 10, '12 by AnonRNCThis is a very interesting topic and a fabulous discussion. I have a couple of things to add.
In 14 years of NICU/Peds nursing (plus 4 as a CNA), I have never seen a "slow code."
However, in the NICU, we do sometimes have "limited codes" and in those cases the do's and dont's are clearly in the MD order. For example, a baby with overwhelming sepsis and metabolic acidosis on full ventilator support, fluid resuscitation, sodium bicarb, antibiotics, and pressors to maintain BP...the order (after discussion w/family about "futility of care") was no compressions if his heart rate slowed on its own. On the other hand, if the patient experienced bradycardia due to accidental extubation, we could do compressions while reintubating. And that plan of care crystallized something for me:
(1st point) CPR does NOT 'bring them back.' What CPR DOES do is buy you some time while you correct the problem that caused the arrest.Read that again; it's important. In the case of overwhelming sepsis and acidosis, there wasn't anything more we could do to correct the problem (we'd already given everything we had to fight infection & correct acid/base balance), so chest compressions would not be indicated. In the case of accidental extubation, we could reintubate and "fix" the problem, so chest compressions would be indicated.
(2nd point) It is vital to recognize that if CPR does happen to 'bring them back' (to spontaneous circulation - i.e. a pulse), that survival to discharge rates are quite low. That interim time results in huge financial charges, pain and suffering for the patient, and emotional distress for the family.
(3rd point) Families don't usually REALLY know what they're saying when they say yes or no to resuscitation. I think we overburden them with the decision making. We are asking them to do something extremely difficult; we're asking them to say "Let my Mother/Husband/Daughter/Lover die." I think we would be wiser to make the decisions ourselves - in most cases. "Your father has had a debilitating stroke from which he will not recover his ability to speak, eat, walk, or talk. He probably does not recognize you or understand anything happening to him. Because of his co-morbidities he is now in multi-system organ failure. Despite our interventions, eventually this will cause his heart to stop and he will die. Would you like to be with him at that time? Would you like spiritual support? How can we help you through this sad and difficult time?"
(4th point) We need to have more conversations around the topic of "futility of care," rather than just pressing on with treatment after treatment.
(5th point) Advance directives (living wills) can help. Nurse know better: we should ALL have one. Here is one of the best I've ever found. http://compassionwa.org/wp-content/u...web-secure.pdf Don't worry that it's supposed to be for Washington State because - GUESS WHAT - advance directives are NOT legally binding. Therefore, advance directives should be coupled with CONVERSATIONS with your loved ones. And I heartily agree with the earlier poster who made a friend (not her spouse) her DPOA.
(Stepping off soapbox - thanks for listening)
- 2Dec 10, '12 by somenurse
I wouldn't know, i kinda doubt it, it takes a pretty cold person to allow mom to suffer so you can have her check,
but, more often,
in the times i've assisted some doc helping a family D/C the full code order, or agree to remove the vent, etc, (often done in sort of family-conference kind of set up)
it seems to me, like 70% of the time,
it is the long distance relative who is fighting tooth and nail to keep the full code order, or the tubefeed/vent, etc, all going.
The stand-by kid (when i say kid, this could be the adult child in their 50s)
who has cared daily for the person, who has seen the decline day by day, living nearby the now dying person,
is usually (not always, but usually) far far more willing to realize, "Yeah, Mom is too sick to keep coding her, and her quality of life is mostly just pain and confusion nowadays."
i can just about pick out the long distance kid in the group. I never know if it is cuz they are so far away, they don't realize how sick 'Mom' is, or is it guilt (deserved or UNdeserved) or is it some ache for more time that kid needs/wants to catch up lost time, (?)
imo, it's so often, that long distance relative who wants to keep on coding, keep the vent on, and last to realize, that Mom is sliding into home plate now.
of course, as we all know,
every family is a unique mosaic, and there's no rule. Such an inside-out, vulnerable time for any person....living wills can sometimes be such a comfort in those times, imo.
but, i swear, i can often pick out that long-distance kid in the group.
- 1Dec 10, '12 by Anoetos
In fact, I am confident that I have witnessed it.
- 0Quote from AnonRNC*** I agee, if by "we" you mean nurses. Physicians would be only marginaly better than families. Lot's of them do not want to make decisions either.(3rd point) Families don't usually REALLY know what they're saying when they say yes or no to resuscitation. I think we overburden them with the decision making. We are asking them to do something extremely difficult; we're asking them to say "Let my Mother/Husband/Daughter/Lover die." I think we would be wiser to make the decisions ourselves - in most cases.
- 0Dec 10, '12 by JoyfulNurseLPNThis article gave me chills. I have heard about ''slow codes'' before but
I wrongfully assumed they were some sort of urban legend or medical myth
that had existed for eons but weren't really part of reality.
The behavior of the other staff is particularly disturbing and frankly, unethical.
I was recently informed that one of my prior co-workers at a LTC facility arrived
on her unit only to discover a patient had passed away and was cool to the touch.
The patient was a full code but CPR was not initiated. Both the supervising RN
and that nurse were fired on the spot.