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 nursing practice when I was... Read More

  1. 0
    Quote from MomRN0913
    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.
    I am curious, what sort of "event" are we talking about? Like, she had a vacation coming up and didn't want to potentially deal with a funeral?

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  2. 0
    Quote from monkeybug
    I am curious, what sort of "event" are we talking about? Like, she had a vacation coming up and didn't want to potentially deal with a funeral?


    I can not speak for the person who posted that, but, possibly, the daughter knew that some hospices require a person to be a formal DNR to be their patient, possibly this remark refers to the daughter's need for in-facility respite care so the daughter could attend some event or trip?
    this is just a guess, though, as that isn't my post, just recalling that occasionally, frequent-flyer families can become very savvy about knowing how to most adeptly get the care to fit their current needs.

    slightly off topic to this thread, but possibly related to this here post above,
    Eons ago, hospitals used to get a few of what we called our "holiday patients", this meant, an otherwise stable-but-req'd-much-care/"couldn't be left alone" type of person,
    would end up being admitted to the hospital, to coincide with the family's plans to go on vacation. Most typically, these patients were wealthy and sometimes, the carergivers were personal pals of the docs. Hard to believe this kind of thing ever happened, but, it did.
    the patients would be admitted with a diagnosis, of course, and we'd even do some tests that first day or so.
    This would not fly today, at all, lol!! THINGS CHANGE over time in patient care.
    *Some* of the stories in which some readers might be agape over, may have occurred in another time, with different settings, different mindsets, different options, different limitations.
    who knows.

    Possibly, who knows, things that nurses see and do today,
    in decades to come,
    will cause alarm or abject horror,
    to THEIR younger counterparts
    on some future date in time...who knows. Things we did in the past, we thought were best thing to do with what we understood at the time,
    and today, it is smack opposite. This could happen to today's nurses, too, maybe someday, who knows.
    (i'm referring to just 'general' nursing rules. Things, rules, ideas, standards, settings, options, etc, all DO change over time.)

    anyway

    so perhaps, the person replying *might* be refering to some manipulation of getting hospice respite care provided (by having her mom labelled a DNR) to free Dtr up, no idea if that is what the other poster above refers to, only just a guess.
  3. 2
    btw, those who are horrified about slow codes,
    would be aghast if they knew what "snowing" a terminally ill patient meant.

    This was done from time to time, to terminally ill patients, in much pain, who were actively dying. The doctor would write a hefty morphine order, "prn distress, discomfort". Ordered it could be given pretty often.

    The morphine was more than the person could process and excrete, it built up over a few days. Most often, the families were not aware of this, it was a decision made by the doc.
    and each nurse could decide, when patient was her patient was under HER care,
    whether or not she'd give a dose, or not. most nurses gave it. There was sometimes a range of doses to choose from, too, from moderate to hefty.

    We called this "snowing" the patient. It was not common, it was mostly done only for severely miserable patients facing a horrific, painful death.

    Call it what you want, but, it was a peaceful death. It's what i'd want if i was in that much pain, too.
    GrnTea and BrandonLPN like this.
  4. 1
    Snowing - of a sort - still happens. When I've seen it, it's been normal, rather than "hefty" doses, but we knew the patient wasn't clearing it well due to disease process. I've not seen it to the point where the patient is completely unresponsive, but I've seen terminal patients be medicated for every little twitch. Many times when taking a patient off support - and I'm talking about patients so critical that they are expected to die in under five minutes - I've seen docs push a big bolus of narcotic. I have no problem with that. The Hospise and Palliative Nurses Association's position statement is a good read. http://www.hpna.org/pdf/providing_op...tement_pdf.pdf

    Sorry for the thread-drift.
    somenurse likes this.
  5. 0
    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.
    Wow. There was actually DEBATE about this - whether or not one should PRETEND to do his or her job? That creates so much cognitive dissonance in my head. What's the point of pretending? You either ARE trying to resuscitate the person or you're not. (Not you personally, of course)

    To pretend to code seems as though it would be perpetrating a fraud on the patient, the patient's family, the facility, one's own sense of ethics, etc. (Not to mention the possibility of financial fraud, when I really think about it).
  6. 0
    Quote from Jean Marie46514
    btw, those who are horrified about slow codes,
    would be aghast if they knew what "snowing" a terminally ill patient meant.
    For whatever reason, I don't see this in the same light, particularly if it is not against the patient's or family's wishes.

    I think for me it's kind of an authenticity thing. You either do something or you don't do it. You don't pretend to do it.

    If you give medication, you can honestly document it. How do you document a slow code though without falsifying? How would you explain it if you ever had to go to court? It seems as though you would be put in the position of either lying, or admitting that the aim wasn't really to resuscitate.
  7. 1
    I thought about this thread during my last rotation and it was a situation I hadn't considered regarding 'slow codes.'

    A patient was transferred in from out of the area and had never been with us before; hence no AD on file. Pt had metastatic cancer but came in for a surgical consult not directly related to her disease process. I noted in her record that she was a full code (since she had nothing on file) so I inquired about her code status and she said, "I'm a DNR."

    Had she coded in front of me, I'd have been ethically challenged since she was officially a full code but her wishes were DNR.

    When I mentioned it to the consulting surgeon who would be writing the admitting orders, the doc seemed somewhat put off by my having brought it up.

    Another difficult case was one in which the patient had signed the DNR paperwork and made her wishes for comfort-care clearly known. Unfortunately, her adult child had durable POA and changed her status back to full code and demanded all interventions once she started to crump.
    TheCommuter likes this.
  8. 0
    A patient was transferred in from out of the area and had never been with us before; hence no AD on file. Pt had metastatic cancer but came in for a surgical consult not directly related to her disease process. I noted in her record that she was a full code (since she had nothing on file) so I inquired about her code status and she said, "I'm a DNR."

    Had she coded in front of me, I'd have been ethically challenged since she was officially a full code but her wishes were DNR.
    *** Seems perfectly clear cut to me. Where is the ethical challenge?


    Another difficult case was one in which the patient had signed the DNR paperwork and made her wishes for comfort-care clearly known. Unfortunately, her adult child had durable POA and changed her status back to full code and demanded all interventions once she started to crump.
    *** If I were her nurse I would refuse to code her aginst her wishes. If I were the patient and was coded aginst my wishes the team better hope like heck I don't live through it and wake up cause the first thing I would do is call the police and press charges for battery.
  9. 0
    Quote from Sadala
    Wow. There was actually DEBATE about this - whether or not one should PRETEND to do his or her job? That creates so much cognitive dissonance in my head. What's the point of pretending? You either ARE trying to resuscitate the person or you're not. (Not you personally, of course)
    No one was "pretending" to do her/his job -- it was just a matter of how quickly and vigorously one did one's job.
  10. 0
    Quote from PMFB-RN
    *** Seems perfectly clear cut to me. Where is the ethical challenge?
    That, while she had expressed her personal intentions to me, there was no DNR order in place which means interventions until the doc

    *** If I were her nurse I would refuse to code her aginst her wishes. If I were the patient and was coded aginst my wishes the team better hope like heck I don't live through it and wake up cause the first thing I would do is call the police and press charges for battery.
    The problem is that her son had durable POA and decided to change... which is the legal right that she gave to him.


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