The Slow Code The Slow Code - pg.12 | allnurses

The Slow Code - page 12

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  Nola009 profile page
    1
    My neighbor was found sitting in his living room unresponsive, so his wife called 911. When medics showed up, did a respectful, gentle "slow code" on this 90-something man. It was about the realization that life only goes so far and compassion for the widow. Thx God they didn't take her beloved husband out of the home they'd raised their children in in a black bag. It was about kindness and decency. I saw it, and told his daughter that he went in a very dignified way. Sure he would have wanted it like that. There is a place for this.
    BrandonLPN likes this.
  2. Visit  nurseprnRN profile page
    0
    I am also reminded of a code I saw once. Patient had, if I recall correctly, surgery for esophageal cancer where the community general surgeon basically attached his stomach to his proximal esophageal remnant just south of his tonsils. He dehisced that im a few days and ended up with a horrible mess in his mediastinum and, really, his entire chest. Four chest tubes all draining nasty ca-ca, vent pressures in the 60s, awful mess. The anesthesia group/intensivists managed him as best they could until it became apparent that after a few weeks and increasingly frequent codes that he was just not going to live. They were ripped about the surgeon, but they couldn't get her to do anything and she didn't know what to do anyway, including referring to a real surgery group, but as I said, after awhile it was a moot point.

    So one day she happened to be there when he coded yet again... and they let her run the code. Which, of course, she was also incapable of, and this poor man mercifully passed away.
  3. Visit  dudette10 profile page
    4
    There has been a situation in my family that is particularly troubling. The alert and oriented relative with a terminal illness stated to his wife, "I don't want to be a vegetable." How vague is that?! Anyway, a neuro event occurred that no cause was found, and they were treating empirically. No one knew what the course would be. The wife did everything that was seemingly against the pt's wishes...NG tube for feeding, then a G-tube, but did make the pt a DNR. Miraculously, the pt recovered mental abilities but is bed bound. When he found out his DNR status during the hospitalization, he was livid because, "I want to live!"

    Sometimes, people don't really know what the hell they want, and it makes it harder on the POA.
  4. Visit  Glycerine82 profile page
    0
    92 y/o woman with a prior CVA. R sided hemi, alert and yelling at me to find her blow-dryer. (her hair was wet- I had just showered her).

    I put her to bed, and while getting her settled, she had a massive stroke and died.

    I called the nurses, thinking they would call the MD and then the coroner, as was the usual procedure when we lost someone. Then they yell "FULL CODE", and call 911. They started their "slow code", (pt was gone, bowels voided, no pulse, no respiration's etc.)

    When I saw the medics get there and start CPR on her all I could think was "Dear God, she is going to be so mad if they bring her back".

    She was pronounced at the hospital, thank God. I can't imagine how awful It would have been for her if she was brought back, and I can't even begin to understand why she was a full code to begin with. I am certain it wasn't her choice, though.

    I am also really glad I was able to find her hair-dryer and dry her hair!
  5. Visit  TriciaJ profile page
    1
    Quote from elkpark
    I was in nursing in the days of "slow codes" and the extended debate within healthcare about the ethics of slow codes and the eventual official determination that they have no place in healthcare -- you either code people or you don't. You don't pretend to code them.

    I will never forget, in one of my first nursing jobs a few years out of school, I was working nights on a large general med-surg unit (this was actually an open unit, with rows of beds with curtains between them, not separate rooms); you could see the entrance to the unit from anywhere in the unit. There was an older gentleman who was at death's door and expected to go any time. During the course of the night, someone else had some kind of acute incident (I don't recall the exact details) and died, and we called the code. I remember the few of us on the unit frantically starting CPR, fetching the cart, etc., and wondering, for what seemed like forever, where the !@#$ the code team was. Finally, after an extended period, they came strolling casually around the corner into the entrance into the unit -- and I will never forget them looking down the unit, someone saying, "Oh my God, it's not him!" and then they suddenly started running and springing into action (they assumed, of course, when the code was called, that it was the older man who was already v. close to death).

    That's the only true, obvious, slow code I ever personally encountered. It turned out that the man who had died could not have been saved anyway, his cardiac event was too severe; but I've always wondered since then how those individuals on the code team would have felt if it had turned out to be a situation in which someone had died needlessly because they based their actions on that assumption and then found out they were wrong.

    Although they've been denounced as unethical by the larger healthcare community for decades, I'm sure that slow codes do still occasionally take place, just as plenty of other traditional-but-now-outdated practices do.
    That is horrible. I was of the impression that slow codes are now illegal. Either the patient is DNR or he is coded. I understand the use of "slow codes" when end-of-life conversations didn't typically happen. But these conversations should be part of standard care by now, with the patient having the last say in what he wants.
    toomuchbaloney likes this.
  6. Visit  sweetdreameRN profile page
    1
    Quote from Glycerine82
    92 y/o woman with a prior CVA. R sided hemi, alert and yelling at me to find her blow-dryer. (her hair was wet- I had just showered her).

    I put her to bed, and while getting her settled, she had a massive stroke and died.

    I called the nurses, thinking they would call the MD and then the coroner, as was the usual procedure when we lost someone. Then they yell "FULL CODE", and call 911. They started their "slow code", (pt was gone, bowels voided, no pulse, no respiration's etc.)

    When I saw the medics get there and start CPR on her all I could think was "Dear God, she is going to be so mad if they bring her back".

    She was pronounced at the hospital, thank God. I can't imagine how awful It would have been for her if she was brought back, and I can't even begin to understand why she was a full code to begin with. I am certain it wasn't her choice, though.

    I am also really glad I was able to find her hair-dryer and dry her hair!

    ...sorry, not on topic...but hmmm...When exactly did you dry the poor woman's hair? During the code?
    Christy1019 likes this.
  7. Visit  MicsterRN profile page
    5
    The topic is appreciated. Protecting our patients' rights to autonomy is our duty.

    "Being Mortal" (2014) Gawande, Atul, is an excellent, thought-provoking read.

    If you're more in to movies than books, watch "You're Not You" with Hilary Swank.

    The RN's role in initiating the delicate discussion of code status, or rather changing the code status, is really tough. I've never actually performed CPR, but I have accomplished these conversations a few times (thus preventing a code). It was hard. I was scared. Family members were shocked, then cried - the patient is still alive.

    One fond memory (a proud professional moment of mine) was having an intimate conversation with a woman on my inpatient medical rehab unit. She was admitted to med rehab with dx "debility" following initial hospitalization for PNE. She was in rehab to get stronger! After 1.5 wks of intense therapy, she continued the decline. Still witty, laughing, A&Ox4. She said, "When it's time, it's time. But the kids won't let go".

    The "kids" visited in the evening. And I started in: Your mother's code status is Full Code, but let's talk about your mom's wishes and what code status actually means.

    Through sobbing tears, the children supported their mom and code was changed to DNR. She was transferred to Palliative Care. I checked on her before each shift, and then four days later, she was gone.
    Last edit by MicsterRN on Sep 16, '15 : Reason: Typo
  8. Visit  kcmcnamee profile page
    0
    A slow code is unethical AND illegal! I saw quite a few carried out back in the early 80's. They were done when families were insisting on full resusitationon for a terminally ill patient, when the pts. doctors didn't agree with the family. In most cases, it seemed to be the merciful thing to do, but it is still unethical and definitely illegal. In my state families (next of kin) have the right to override a pts. DNR request once the pt. becomes incapacitated. It is a cruel thing to do, since the pt made that decision when they were of sound mind, but it does happen. We, as healthcare professionals, are bound by the law.
    Last edit by kcmcnamee on Sep 17, '15 : Reason: typos
  9. Visit  MunoRN profile page
    1
    Quote from kcmcnamee
    A slow code is unethical AND illegal! I saw quite a few carried out back in the early 80's. They were done when families were insisting on full resusitationon for a terminally ill patient, when the pts. doctors didn't agree with the family. In most cases, it seemed to be the merciful thing to do, but it is still unethical and definitely illegal. In my state families (next of kin) have the right to override a pts. DNR request once the pt. becomes incapacitated. It is a cruel thing to do, since the pt made that decision when they were of sound mind, but it does happen. We, as healthcare professionals, are bound by the law.
    The POA doesn't actually have the right to override the patient's clearly stated wishes in any state. Their legal responsibility in every state is to abide by patient's clearly expressed wishes and to ensure that those wishes are followed. They can help determine what a patient would want in a specific situation by applying their knowledge of the patient's wishes to that situation. This can sometimes make it unclear if they are going against the patient's wishes or not, but they cannot overtly reverse a DNR because it's what they want, rather than their interpretation of what the patient wands.
    JustBeachyNurse likes this.
  10. Visit  subee profile page
    0
    We definitely need more case law with these DNR orders that are ignored. I also do nit believe that it is "illegal" not to resuscitate moribund patients and it is certainly not unethical. I'm uncertain how these Miss Prissypants values get passed on
    Since they are so deleterious to our dying patients. What staff are doing to patients who have (and don't have) DNR orders is battery. I guess things will never change since the dead are unable to pay lawyers' fees.
  11. Visit  elkpark profile page
    1
    Quote from MunoRN
    The POA doesn't actually have the right to override the patient's clearly stated wishes in any state. Their legal responsibility in every state is to abide by patient's clearly expressed wishes and to ensure that those wishes are followed. They can help determine what a patient would want in a specific situation by applying their knowledge of the patient's wishes to that situation. This can sometimes make it unclear if they are going against the patient's wishes or not, but they cannot overtly reverse a DNR because it's what they want, rather than their interpretation of what the patient wands.
    Do you have some documentation of this? I ask because I have heard attorneys speak at nursing and ethics conferences and say exactly the opposite, that you need to be really careful about who you choose to be your POA because, once you're incapacitated and the POA becomes valid, that person is not bound by your wishes and is free to make whatever choices s/he feels are most appropriate.
    chare likes this.
  12. Visit  MunoRN profile page
    0
    Quote from subee
    We definitely need more case law with these DNR orders that are ignored. I also do nit believe that it is "illegal" not to resuscitate moribund patients and it is certainly not unethical. I'm uncertain how these Miss Prissypants values get passed on
    Since they are so deleterious to our dying patients. What staff are doing to patients who have (and don't have) DNR orders is battery. I guess things will never change since the dead are unable to pay lawyers' fees.
    At least in my part of the country, case law is pretty clear. I know that cultural views on futile of life care are not the same everywhere in the US, so maybe the legal precedent varies as well. But in every place where I've worked, risk management is very vigilant about ensuring that we do not subject patients to treatments at the end of life that they were able to specifically state they don't want, particularly if the POA comes right out and says they are making a decision based on what they want, not what they patient would want. That potentially opens the staff and facility up to assault and other charges, not to mention civil suits.

    In addition to that, resuscitation is a medical treatment, and Physicians are under no obligation to offer treatments where no benefit can be expected and are actually obligated to ensure that futile treatments are not performed.
    Last edit by MunoRN on Sep 17, '15
  13. Visit  MunoRN profile page
    0
    Quote from elkpark
    Do you have some documentation of this? I ask because I have heard attorneys speak at nursing and ethics conferences and say exactly the opposite, that you need to be really careful about who you choose to be your POA because, once you're incapacitated and the POA becomes valid, that person is not bound by your wishes and is free to make whatever choices s/he feels are most appropriate.
    An overview; The Responsibilities of Medical Durable Power of Attorney for the Elderly | LegalZoom: Legal Info

    A DNR order is even less subject to being overturned since it is not an advanced directive, it's a medical order. If for instance a patient is in the hospital with a particular medical condition, and after discussion with the doctor the patient decides if that course results in cardiac or respiratory arrest that they would not want to be resuscitated, then the patient's wishes have been established and the POA would have to present a valid argument as to why they believe their wishes have now changed.

    That being said, you do still need to be very careful about who you chose to be you POA since they will be responsible for applying what they know about your wishes to medical decisions where those decisions have not been specifically determined in advanced directives, so it needs to be someone you trust to do this accurately.

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