The Slow Code The Slow Code - pg.13 | allnurses

The Slow Code - page 13

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  subee profile page
    2
    My husband is not my POA because he has no medical background and is loathe to discuss end of life issues. I'm fortunate enough to have a close friend MD who is attuned to my philosophy of life and was willing to take this on. My husband would never pull the plug and I can't trust him to do the right thing for me. Incidentally, he just says that he wants everything done for his dying vessel and a large pyramid after he "passes".
    Christy1019 and imintrouble like this.
  2. Visit  MunoRN profile page
    0
    Quote from subee
    My husband is not my POA because he has no medical background and is loathe to discuss end of life issues. I'm fortunate enough to have a close friend MD who is attuned to my philosophy of life and was willing to take this on. My husband would never pull the plug and I can't trust him to do the right thing for me. Incidentally, he just says that he wants everything done for his dying vessel and a large pyramid after he "passes".
    You can also hire a professional proxy, which I wasn't sure what to think of at first but after having a few patients who used them it can actually be very beneficial. I thought families might be offended to find out someone they've never met will be making the decisions, but as it turns out they've been relieved not to have that responsibility. The ones I've dealt with included a nurse, an NP, and a retired MD, which meant they were able to have a much more meaningful discussion with the patient about various possible scenarios, unlike a non-healthcare family member or a lawyer.

    http://newoldage.blogs.nytimes.com/2...enforcer/?_r=0
  3. Visit  MunoRN profile page
    0
    I think my link above might be broken, here it is again:
    Hiring an End of Life Enforcer - NY Times
  4. Visit  calivianya profile page
    1
    Quote from MunoRN
    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.
    I need to move to wherever you live. The only thing that is extremely clear to me is that almost every DNR that goes unconscious gets coded if family is there when the event happens at my facility. I'd say at least 1/3 of the codes on my unit are on "DNRs" whose families changed their minds.

    It's awful. And don't even get me started on the POS family members who berate the 80s+ patient until the patient cries into changing her mind and being a full code again, because "you just want to die and leave your family? You're so (insert a ton of cuss words) selfish."

    Coding those poor fragile elderly people who only agreed to be full codes because their families bullied them into it is the only time I would seriously consider attempting a slow code. I think slow codes are horribly unethical, but breaking bones/puncturing lungs in a person who is clearly ready to die is even worse. Unfortunately, the open visitation means the family members are often in there during the code, so we can't even slow code if we really wanted to.
    subee likes this.
  5. Visit  MunoRN profile page
    1
    Quote from calivianya
    I need to move to wherever you live. The only thing that is extremely clear to me is that almost every DNR that goes unconscious gets coded if family is there when the event happens at my facility. I'd say at least 1/3 of the codes on my unit are on "DNRs" whose families changed their minds.

    It's awful. And don't even get me started on the POS family members who berate the 80s+ patient until the patient cries into changing her mind and being a full code again, because "you just want to die and leave your family? You're so (insert a ton of cuss words) selfish."

    Coding those poor fragile elderly people who only agreed to be full codes because their families bullied them into it is the only time I would seriously consider attempting a slow code. I think slow codes are horribly unethical, but breaking bones/puncturing lungs in a person who is clearly ready to die is even worse. Unfortunately, the open visitation means the family members are often in there during the code, so we can't even slow code if we really wanted to.
    If those DNR orders were written when the MD could discuss the patient's wishes with them then that really shouldn't be happening, even more so if coding the patient could be considered futile.

    There are a number of references that say the same basic thing:
    If your doctor has already written a DNR order at your request, your family cannot override it.
    https://www.nlm.nih.gov/medlineplus/...ons/000473.htm
    If your doctor writes a DNR order at your request, no one can override it.
    https://www.ohiobar.org/ForPublic/Re...mphlet-24.aspx

    CPR is a medical treatment and the same basic rules apply. If a patient had the option of high risk open heart surgery or comfort care and the patient expresses to the surgeon that they do not want surgery, imagine if after the patient lost the ability to communicate their wishes the family told the surgeon to do surgery anyway, I would hope every surgeon would refuse to do that. For patients where CPR would be futile that would be like if the surgeon declined to offer surgery and the patient didnt' want it anyway, and then the family told the surgeon to do surgery, that's pretty clearly not appropriate in that situation.

    Aside from the basic premises of not offering inappropriate treatments which protects MDs, your state of NC has an additional law that specifically shields physicians from liability for making a patient DNR due to medical futility.
    calivianya likes this.
  6. Visit  elkpark profile page
    1
    Quote from MunoRN
    If those DNR orders were written when the MD could discuss the patient's wishes with them then that really shouldn't be happening, even more so if coding the patient could be considered futile.
    We all know that lots of things "that really shouldn't be happening" happen in healthcare. I've personally seen a number of situations over the years in which advanced directives were ignored and overridden because the family felt differently. There was one particularly grotesque situation in which the woman with CA that had metastasized all over her body after she had been fighting it for years, who was ready to throw in the towel and stop treatment (and was asking for that), was continuing to receive chemo and other treatment injections through her IV as she lay there in the hospital bed, saying, "No ... Stop that ... Don't do that ..." to the nurses giving the injections because her two daughters insisted that everything be done to keep Mom alive. I was aware of this because I was on the medical center's psych C&L service, and we had been consulted to evaluate her mental capacity to refuse further treatment (and choose to die). We said that she had capacity and her wishes should be respected. The hospital legal department and the attending physicians ultimately didn't care.

    I've been told by the legal counsel of more than one hospital over the years that hospitals will always side with the relative who wants the person kept alive because no one has ever sued a hospital for being kept alive, but plenty of people have sued hospitals for letting their loved one die ... Advance directives, POAs, etc., etc., are nowhere near as clearcut and definitive as people think. Just because you've done everything you're supposed to do to ensure your wishes will be followed, that doesn't mean they actually will be followed if a family member who is still going to be around after you're gone feels differently.
    calivianya likes this.
  7. Visit  freyarn profile page
    0
    I am a patient advocate first and foremost. If my patient wants to be a full code, we are coding you. Someone has explained to them that they won't live forever, that it would be a painful and long recovery - if that's their desire, who am I to deny that?

    I never have and never will participate in a slow code because I will just feel dirty.
  8. Visit  Double Dunker profile page
    0
    We had a patient not too long ago that had all the paper work in order to be a DNR/no code who we rapid responded. Docs came in and decided to transfer patient to ICU where they intubated her. No family was around at the time, and the family that had been in during the day supported the DNR decision. It was the doctor who overruled it all. Patient was removed from life support the next morning after all the family had been called.

    This week we had a patient that had all the appropriate paper work in the chart to be a "no code" but the doctors hadn't changed the code status in the chart. When the night doctor was paged about it, he said he'd leave it for the day shift doc take care of. House supervisor told my co-worker, "Well, if she codes, there are ways to deal with it" pretty much saying we would slow code her.

    I hate how the fear of lawsuits dictates how we determine the patient's "best interests".
  9. Visit  TinaCundiff profile page
    0
    I witnessed my first slow code while in an ICU. It was a patient on a vent that was in their 80s. He had been chronic for about 4 weeks with no response. The ER doctor came and do E it himself.
    I work in a state extended care/psych facility now. Most residents have no family so a social work from DHHR makes the decision as to if they are DNR,comfort care, or a 14 day vent, gtube, then she decides from there. She doesn't know these people. She has no medical background and doesn't come and speak with the nurses about the resident. She will sometimes talk to the residents up and moving but they are not able to make decisions for themself. It is sad to see resident have a gtube then be put on hospice and not get any food or fluids because we aren't allowed to use the gtube while if the resident is able to eat they still eat as long as they can. It is an ethical slippery slope but I will and have worked the codes as I would with any patient.
  10. Visit  Jensmom7 profile page
    2
    Quote from TinaCundiff
    It is sad to see resident have a gtube then be put on hospice and not get any food or fluids because we aren't allowed to use the gtube while if the resident is able to eat they still eat as long as they can. It is an ethical slippery slope but I will and have worked the codes as I would with any patient.
    Are you talking about a Hospice patient who has a g-tube and is no longer responding?

    If so, then no, you generally wouldn't continue tube feeds-if they were unresponsive and didn't have a g-tube they wouldn't be eating or drinking, right? At that point it's meticulous mouth care, for comfort.

    And a Hospice patient with a g-tube who is still responsive, albeit possibly confused, could still continue feeds and flushes-what we do in that case is decrease the amount they get over time, which mimics the gradual appetite decline that patients without g-tubes experience.

    Also, the majority of Hospice patients have a DNR (not a requirement, but recommended). In that case, there wouldn't be ANY code response, slow or not.
    TheCommuter and Farawyn like this.
  11. Visit  LeChien profile page
    0
    I've participated on a slow code before. I was called to another nurse's patient's room. I was the one who grabbed the crash cart and AED. The other nurse was just standing there - a seasoned nurse with 20+ years experience. I put the AED pads on and initiated CPR. I encouraged the other three staff members to switch off with me. The lady didn't make it as her pacemaker quit on her. I was in awe that the nurse didn't initiate CPR before I got there.
  12. Visit  TheCommuter profile page
    0
    Quote from staceydoodle429
    I've participated on a slow code before. I was called to another nurse's patient's room. I was the one who grabbed the crash cart and AED. The other nurse was just standing there - a seasoned nurse with 20+ years experience. I put the AED pads on and initiated CPR. I encouraged the other three staff members to switch off with me. The lady didn't make it as her pacemaker quit on her. I was in awe that the nurse didn't initiate CPR before I got there.
    Thanks for sharing your personal 'slow code' experience.

    Since you are in your early 20s and likely haven't been a nurse for an extremely long time, your recollection is anecdotal evidence that slow codes may still be taking place in hushed secrecy.
  13. Visit  Mommavik profile page
    0
    I agree with you; I've participated in many codes; and one thing I've learned: it doesn't matter what we do, if it's their time to die they're not going to be successful; I've had one patient that over 45 minutes was spent on coding; the pcp came in at the end and called it. When I was sent back in to prepare the patient to be transported to the funeral home, he suddenly started breathing and woke up on his own! This was about an hour after his code was called! Last I heard this man was still alive but remembers nothing about this hospitalization

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