The Slow Code - page 15

by TheCommuter Senior Moderator | 27,213 Views | 148 Comments

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. 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.
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    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.
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    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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    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.
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    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.
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    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.
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    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!
  8. 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.
  9. 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.


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