The Slow Code - page 2
by TheCommuter 26,690 Views | 148 Comments Senior Moderator
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
- 22OK I am going to disagree. A proper slow code is an art. How to make it look like you are doing something when not really trying to save the patient. As far as I am concerned the slow code will be needed as a self defence mechanisim for health care providers so long as our society maintains it's irrational refusal to talk openly about end of life issues and accept that dying is part of life.
I am a full time rapid response nurse. I am the code administrator for my hospital and the alternate code team leader until / if the "code chief" (usually a senior med or surg resident) arrives on the scene. Occasionaly I will run the entire code like the few times there have been two codes going on at the same time or the code chief doesn't show up for some other reason.
ON several occasions I have refused to code a patient at all. Other times I will let the team know this is going to be a a "show" or "slow" code. In every instance I had reason to know the patients wishes and knew that being coded was aginst their wishes. For example one man with severe necrotic bowel, literaly rotting from the inside out did not wish to be coded. When he was alert and oriented early in his hospitalization he made the informed decision to be a DNR. Later, when he could no longer make his wishes known, his estranged wife changed his code status to full code. The real problem is that she would be allowed to do that at all. That his weak kneeded-fearful-of-a-lawsuit physicians agreed to the change in his code status is another major problem that needs to be adressed. However all that is water under the bridge when "code blue" is called on him.
If the patient has made an informed decision to be full code I will code the heck out of him. I will not go aginst a patient's informed decision and wishes. I hope it doesn't cost me my job (so far not an issue) but if i does it does.
- 21Dec 6, '12 by echoRNC711Having worked on a code team my experience was there is no "kind of " code,it either is or it isnt. It is my job to act unless there is a DNR order but ...before anyone pats them self on the back for heroism often this is the picture...... A pt zapped so many times the room smells like bacon, a pt who has been "down" for so long you may restore the heart but there is little brain left, a lengthy code where we get the pt back so they can have the 3mth slow excruciating death.As a nurse I have learned there are far worse cruelties than dying.
Yes ,these are the rules and need to be followed but I am wondering.....If you were one of the pt described here,would you be grateful? Is it the care would you would hope that your family gets ?
The reality I learned (and was shocked at ) is few pt survive a code unless it was witnessed. In a CVRU an impending code can be anticipated and the action is immediate, which yields a good outcome. Rapid response has helped the odds but back in 2000 when I was on the code team it seemed to me about 2-3 out of 10 make it. (their functioning capacity afterwards I don't know )
Personally, I feel the problem lies that we don't take the time to explain proxys in a way pt understand. This should be done on admission .The hospital culture sees death as failure so we wait too long to even ask for a DNR when it clearly needs addressing.. Death is part of life and continuing to deny this creates these horrible codes. It is our duty to follow pt wishes , so it would behoove us greatly to spend the time at admission to find out what those wishes are.
We need a greater respect of death by addressing its presence. To not know a pt wishes is as grievous an omission, to me ,as not performing the code. (I have a proxy but I (semi) joke that if it is not honored I will make it my mission to personally haunt that person after death ) People say, "we die when its our time", or "only God decides when we die ". If a pt is blue, cool and clearly dead, hasn't death been decided ?......Have we reached a point that we are coding people to the point that we have actually taken God out of the equation.
So do I act decisively in a code,absolutely but I can privately feel that to do so sometimes is to deny the sacredness of both life and death. Care about your pts, invite a proxy discussion.
- 0Dec 6, '12 by OnlybyHisgraceRNI have seen something similiar in my 3 years of nursing. An elderly man coded, and initially everything was being done, but then the the doc decided to verbally end the code, but everyone involved kept documenting as if the code was still happening. Needless to say, I was shock but apparently it happens.
- 1Quote from OnlybyHisgraceRN*** What did you think should have happend?I have seen something similiar in my 3 years of nursing. An elderly man coded, and initially everything was being done, but then the the doc decided to verbally end the code, but everyone involved kept documenting as if the code was still happening. Needless to say, I was shock but apparently it happens.
- 11Dec 6, '12 by elkparkQuote from echoRNC711Yes, this is what the general public (and even lots of healthcare people) doesn't get. When I was working for the VA years ago (which is where I witnessed the code team taking their own sweet time because they thought they knew who we were calling the code for), the VA did a huge national study of clients who got coded within VA hospitals around the country. I forget the exact figures, but the final results showed that only a tiny percentage of those coded and "brought back" in VA hospitals ever left the hospital. The vast majority of those resuscitated simply lived a little longer in the hospital and then died again. Almost none of the individuals actually resumed any kind of life anyone would want.The reality I learned (and was shocked at ) is few pt survive a code unless it was witnessed.
If it were up to me, I would make the national standard that everyone is a DNR unless there's some darned good reason to resuscitate them (y'know, young, healthy adult, some freak accident with electricity that stopped the heart ... )
- 14Dec 6, '12 by somenurseI have seen many a slow code. Maybe they have are not done so much anymore, since several nurses wrote they'e never seen one. For some, especially END STAGE DISEASE PROCESSES going on, the code is robbing them of their one chance to die a peaceful death, coding them is a violent waste of time, and if you do get Mr Jones back, he's not really "Mr Jones" anymore, but, more likely, a brain dead individual who lingers and suffers, and causes extended suffering for the family, too, and forces the family to make extremely difficult decisions, when the permanently tube-fed, vegetative patient "lives" for months and months, dying at an inch at a time, slowly.
I remember as a very very young nurse, a code actually bringing back some 90 years old alzhimer nursing home patient, who had been brought to E.R., when it was found she had had died in her sleep, coded all the way. Amazingly, the code did get a heartbeat going again. Fixed pupils, couldn't quite breathe enough to get the ET removed, sent to ICU to be kept on vent (which back then, were NEVER ever ever removed, once in place) and i was elated, just elated, we had "saved" her. I recall the doc looking at me, and saying "oh yeah....good 'save'. "
and looking very sad. His reaction was such a surprise to me, it stuck with me all these many decades later. Now i do understand his sadness. but i didn't back then.
In the old days, it was always assumed a person (even a terminally ill person) usually "wanted" to be coded. Few if any ppl truly realize what it is that they are signing up for, though. They picture end-results of codes to be like on tv, where the exact same brain that existed prior to the code, wakes up and smiles at their family.
DNR options were not discussed that often, and offered and accepted the way they are today.
The general mindset of the population, and of many older ppl even now,
was DNR was "giving up". Yes, i've seen some slow codes.
There are worse things than death.
no doubt, others will slam this post, and that's fine. Technically, and legally, they are right, even terminally ill ppl, even extremely elderly ppl, should all be brutalized if we catch them slipping peacefully away
dying a natural death,
if there isn't a formal DNR order written. Yeah, sure, that IS legally right, no argument here on that. And yes, our job IS to squeeze our eyes shut to the end result of coding terminally ill ppl, and to just promote life, that any and all form of signs of life, must be preferable to the chance of having a peaceful death.
yes, yes, that is our job.Last edit by somenurse on Dec 6, '12
- 12Dec 6, '12 by Esme12 Senior ModeratorYears ago......back in the ice age.....it's all we had. The MD would write in the progress notes that the medical condition was such that heroic efforts were futile and that a "slow code" was indicated. There were no DNR's and the family wasn't involved in the decision nor the discussion and we told...."everything was done, we are sorry, and they didn't suffer".
Simply put it's what we did. The family was not apart of the equation. I think, in some instances...removing the families emotions...saved some patients from being tortured in ICU for endless days with tubes shoved everywhere.....and families were comforted that everything was done". We would answer all codes the same and once in the room, behind close doors...... we would
Yes we lied to them....but they were little white ones. There are times I miss those times somewhat for I think the empowerment of the patient and family has lead, somewhat, to the sense of entitlement that families now have...... there were good thinkgs about the good ole days...like visiting hours when necessary.