The Slow Code - pg.11 | allnurses

The Slow Code - page 11

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... Read More

  1. Visit  allegator profile page
    1
    Never mind slow code, what about no code? That's what the doctors and nurses did to my father a decade ago, and, despite my best efforts to hold the bad actors accountable, they got away with it.
    Last edit by Esme12 on May 18, '13 : Reason: TOS
    Esme12 likes this.
  2. Visit  SweetMelissaRN profile page
    1
    The only time I've ever participated in a "slow code" (didn't realize there was a name for it!) was when a pt coded after telling me, my charge nurse, his family, and the doctor he wanted to be a DNR. He coded within 45 minutes of saying this while we were trying to get his primary doctor to write a DNR order. I've never heard of someone being a known full code (after knowing about DNRs) and having nurses not try to save their life... That's really terrible..
    allegator likes this.
  3. Visit  calivianya profile page
    1
    Holy moly, reading this thread made me nauseated. I had no idea anyone did stuff like this for real, ever, and that anyone who works in a field as "trusted" as nursing could ever go along with it. This thread makes me really question why nurses are trusted at all.

    It is not our decision as healthcare professionals what to do when a patient codes. It can be the patient's decision, and it can be the family's decision, but it is NOT ours.

    I agree that it is ridiculous how far our society will go to prolong life, and I agree that there are people who should be DNR but aren't. I agree that a gentle death is more compassionate than breaking all the ribs on a 95 year old cancer patient and leaving him a vegetable for months, but that is NOT our decision. It doesn't matter if the patient didn't really understand that what makes him "him" isn't coming back, despite all explanations. It doesn't matter that it makes our hearts hurt to do damage to these poor, frail people. OUR opinion does not matter, at all. It is the patient's opinion that matters, and I really think anyone who slow codes someone who is a full code and wants to be resuscitated shouldn't work in healthcare and should also be charged with involuntary manslaughter (at least) and thrown in jail if they go along with this sick violation of a person's rights. Really.
    allegator likes this.
  4. Visit  allegator profile page
    0
    Calivianya, if only more in the health care field felt as you do!

    You can't go down the slow code road because it's a slipperly slope. Refusing to break a 95-year-old cancer patient's ribs invariably leads to what happened to my father; elderly but not 95, demented but only mildly, some swallowing difficulty due to a Zenkers, but no disphagia, good qol, etc. All-too-easy for health care pros playing god to ignore those distinctions. And once the deed is done the system swings into action to protect those fine doctors, nurses and hospital admins. (I had a link to my website in my previous post in case there was interest, but I see it was removed due to tos.)
    Last edit by allegator on May 23, '13
  5. Visit  MunoRN profile page
    1
    Quote from ♪♫ in my ♥
    The problem is that her son had durable POA and decided to change... which is the legal right that she gave to him.
    POA's don't actually have the legal right to go against the expressed wishes of the patient. They are legally obligated to ensure that the patient's expressed wishes are being followed.
    GrnTea likes this.
  6. Visit  MunoRN profile page
    1
    Quote from calivianya
    Holy moly, reading this thread made me nauseated. I had no idea anyone did stuff like this for real, ever, and that anyone who works in a field as "trusted" as nursing could ever go along with it. This thread makes me really question why nurses are trusted at all.

    It is not our decision as healthcare professionals what to do when a patient codes. It can be the patient's decision, and it can be the family's decision, but it is NOT ours.

    I agree that it is ridiculous how far our society will go to prolong life, and I agree that there are people who should be DNR but aren't. I agree that a gentle death is more compassionate than breaking all the ribs on a 95 year old cancer patient and leaving him a vegetable for months, but that is NOT our decision. It doesn't matter if the patient didn't really understand that what makes him "him" isn't coming back, despite all explanations. It doesn't matter that it makes our hearts hurt to do damage to these poor, frail people. OUR opinion does not matter, at all. It is the patient's opinion that matters, and I really think anyone who slow codes someone who is a full code and wants to be resuscitated shouldn't work in healthcare and should also be charged with involuntary manslaughter (at least) and thrown in jail if they go along with this sick violation of a person's rights. Really.
    It's our decision as well. MD's have the legal right, not to mention an ethical responsibility, to avoid medically futile treatments that only cause the patient harm. A patient has the right to chose to be a full code, but MD's don't have to honor that any more than they are required to perform open heart on someone with a 100% chance of dying on the table.
    morte likes this.
  7. Visit  allegator profile page
    1
    Quote from MunoRN
    It's our decision as well. MD's have the legal right, not to mention an ethical responsibility, to avoid medically futile treatments that only cause the patient harm. A patient has the right to chose to be a full code, but MD's don't have to honor that any more than they are required to perform open heart on someone with a 100% chance of dying on the table.
    Yes, it's your individual decision if you play by house rules. I think most hospitals would require you to sign a form asserting your refusal to provide "medically ineffective" treatment. The hospital would then be on the hook to secure their patient another doctor or to attempt a transfer to a different facility willing to treat. Pending such action they must provide life-sustaining treatment if the patient's life is in danger. This process mirrors the law in many, if not most states.

    The problem arises when doctors (and the nurses who follow their lead) have tacit understandings amongst themselves regarding intubation and coding because they know from experience what is in the patient's "best interests." They allow their patients to slide into respiratory failure by avoiding aggressive and preventative tx, and then they play the slow-code game. Please tell me this never happens. And yes, with a stage 4 lung ca patient they may be right, but as I say, it's a slippery slope and people in the "trust" business have no business pulling that kind of stunt, much less getting away with it.
    calivianya likes this.
  8. Visit  MunoRN profile page
    2
    Laws vary by state, some require a court order to enter a DNR order against patient or family wishes. What's defined as 'medically futile' is fairly narrow. CPR would have to provide absolutely no potential benefit. This usually occurs when cardiopulmonary arrest is due to an untreatable progressive disease/injury which is the underlying cause of the arrest and is unaffected by attempts to reverse the arrest. No matter how much CPR anyone does when someone's brain severely herniates after a massive stroke, it won't change anything, the problem isn't the heart or lungs.

    In these relatively rare situations, healthcare providers must follow the same rule that applies to everything else they do; do no harm. 'Do no harm' of course isn't really that simple. We do harm all the time, we allow and even take part in medical acts that may be very likely to cause the patient harm, so long as there is some potential for benefit the harm can be justified. Without that potential benefit, there is only harm.
    morte and TheCommuter like this.
  9. Visit  jadelpn profile page
    1
    Both unethical and immoral. It is not a healthcare teams place to make everyone a DNR.
    But it happens every day.
    There needs to be more education of newer nurses on the "slow code" aspect of someone not breathing and no pulse, along with termination for anyone that is a non-participant in the code process but "puts on a show" for EMS.
    Duty to act.......
    calivianya likes this.
  10. Visit  allegator profile page
    0
    Quote from jadelpn
    Both unethical and immoral. It is not a healthcare teams place to make everyone a DNR.But it happens every day.
    Exactly what happened to my dad. The very first physician order written in the ER said "DNR." Nobody owns up to knowing how it got there and an order written later that evening by the admitting/attending said "Full-code," but if you ask me the damage was already done; a 91-year-old with an alleged workup of contusion, head injury, major concussion with loss of consciousness, congestive heart failure, hyponatremia, pneumonia, septicemia, a wbc of 36,000 with hard left shift (all of these brand new, first-time findings) admitted to a regular floor on half-dose antibiotics. The dye (or die) was cast.

    Does this really happen every day?
  11. Visit  elkpark profile page
    2
    Quote from MunoRN
    POA's don't actually have the legal right to go against the expressed wishes of the patient. They are legally obligated to ensure that the patient's expressed wishes are being followed.
    That's not my understanding (and I've worked on these topics quite a bit over the years). I've heard attorneys lecturing on this topic explain more than once that the reason you should be extremely careful about who you make your POA is because, once you are incapacitated and the POA takes effect, that individual is under no obligation to follow your wishes -- you have given that person the full legal right to make decisions (as s/he sees fit) on your behalf, using her/his best judgment (but not necessarily following your wishes).
    toomuchbaloney and jadelpn like this.
  12. Visit  MunoRN profile page
    1
    POA/AD laws are state specific, but I don't know of any that don't include some form of this provision. This usually includes anything in a living will, but particularly DNR orders. Situations involving a DNR used to be pretty rare since a patient would have to come in to the hospital able to make their own decisions and lose that ability, although now with POLST forms this is fairly common that a patient comes into the hospital with an already active DNR order.

    A couple of examples specific to DNR:

    The legal scope of a POA is to make the patient's wishes known, to the best of their ability, when the patient is unable to make their wishes known. A DNR order is a Physicians order and cannot be overturned by a POA. A POA only comes into play when there are not "clearly stated" patients wishes available. In practice, this essentially means that the POA can do whatever they want, since by definition they are only referred to when the patient's wishes are not known, leaving no way of knowing if they are abiding by those wishes. Whether or not hospitals will actually enforce this is another issue; dead people don't sue, families due, creating an unfortunate situation where hospitals are more likely to bow to the family even when that might go against the wishes of the patient.

    Having a meaningful palliative care team helps. My hospital used to be very leery of making families unhappy, even when it meant violating the patient's wishes. After establishing a palliative care team that actively enforces the expectations of the POA, I've actually been surprised how well POA's take it when their some decision making gets taken away or overridden, POA's understandably have a hard time holding back when appropriate, they tend to view futile actions in terms of "at least we did everything for dad", rather than the more accurate "at least we did everything to dad". Almost always POA's are relieved to have someone else enforce the patient's wishes when they know deep down what the patient really wanted, they just can't bring themselves to act on that.
    TriciaJ likes this.
  13. Visit  jadelpn profile page
    0
    Quote from elkpark
    That's not my understanding (and I've worked on these topics quite a bit over the years). I've heard attorneys lecturing on this topic explain more than once that the reason you should be extremely careful about who you make your POA is because, once you are incapacitated and the POA takes effect, that individual is under no obligation to follow your wishes -- you have given that person the full legal right to make decisions (as s/he sees fit) on your behalf, using her/his best judgment (but not necessarily following your wishes).
    This is absolutely the truth! More than once in my years, the "plan" is all well and good until at bedside, then depending on the situation, minds change and it becomes what the POA/HCP wants as opposed to the patient's wishes. So be really, really clear with who you choose for your POA, because when it comes down to it, decisions are made on understandibly emotional grounds.

    There is more than one resident of skilled care who had a lengthy, detailed "legal" document as to their wishes. Those documents become wildly subjective for some POA/HCP's when it comes down to it. It may be different in other states, but generally speaking, POA's (or HCP's) have the final word. It is not always "keeping someone alive". If one chooses to value quantity over quality (and who are we to judge that decision) there can be and is HCP/POA's who say "no way" and go against those wishes.

    This is serious stuff, and the goal in the perfect world would be comfortable and peaceful. Family gets caught up in patient's "starving" more than anything else, in my experience.

    Families need to have these talks. A POA/HCP is a difficult position to be in.


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