The Slow Code - page 6
by TheCommuter 25,879 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
- 2Dec 6, '12 by somenursewow, NurseCard, that is such a great point, i think you've hit on something there. I do think you just nutshelled one fear that keeps some ppl from signing a DNR form...probably the biggest fear of all, i bet.
i think another reason, is, ppl feel it's "giving up" so so much talk of "fighters" that fighting for a peaceful death, doesn't get enough credit, maybe sometimes.
i think another reason, could include just misinformation about what a code is really like, and how much of the brain is saved, (usually not much) if we do get the person breathing again.
but yeah, NurseCard, i think you hit that one on the head all right, l think some ppl do think, "Aw geez, if we allow Grampa to be a DNR, he'll just not be cared for or treated."
- 0Dec 6, '12 by OnlybyHisgraceRNQuote from PMFB-RNWow. Shocking. I'm shocked that you can slow a code or do a "show" code without proper documentation. Unless I had documentation of the patients' words verbatim in the chart or a DNR note, I would have fully coded the patient. Trust me, I know the feeling or not having the proper paper work and going against the patients verbal wishes. However, if there is no documentation then I have to follow policy and procedure and the nurse practice act.OK 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.
When I worked in bedside, I always asked my patients if they prefer DNR or full code and would document the convo and notify the MD so that changes would be made.
This is one of the things I hated about working in ICU.... not being able to follow patients' wishes due to lack of documentation and follow up.
- 1Dec 6, '12 by KelRN215This reminded me of a patient who I will never forget from a med-surg clinical in nursing school. My clinical instructor arranged for me to spend a day in the MICU. The patient was a man in his 40s or 50s with end stage multiple myeloma. He was intubated, sedated, in multi-organ system failure, with central lines, a G-tube, a foley, a rectal tube... basically any tube you can imagine, this guy had. He was a full code. In his chart, there was a living will which stated "I do not wish to be kept alive artificially. I do not want a feeding tube. I do not want CPR. I do not want to be put on a ventilator." He was a bachelor and his siblings were his next of kin. They believed that he would "want everything done." This man was dying and dying soon. CPR would not have ever saved him. I don't know what happened to him since I was only there that one day but I hope that he wasn't coded when he did die.
I am only 28 but I have already told my family that under no circumstances would I want a feeding tube or a trach. If they were to ever disregard my wishes and insist on futile heroic measures well, then I can only hope that there's an after life so I can come back and haunt the hell out of them.
- 0Dec 6, '12 by redhead_NURSE98!Quote from Jean Marie46514The problem I have with these is that I've seen physicians just see these documents and say "oh they're DNR." Um NO. Therefore I will not be filling one out for quite awhile.You are a great candidate to have a living will drawn up. (or, as it was referred to, during the Obamacare discussions, a "death panel") A living will can state ANYTHING *you* want done, for example--- do everything, no matter what!
Or everything unless i am verifiabley brain dead for 3 days. Or whatever algorithm fits YOUR wishes. It is NOT a "death panel" as so many seem to think it is. It is only a statement of your exact wishes, in various scenarios, to relieve your family of trying to guess what you'd want done in this or that case.
- 1Dec 6, '12 by akulahawkRNI have seen the slow code... never participated in one though, and generally, I refuse to. I have also seen, and suggested heavily to families that when their relative is headed home to get called home that they seek out a DNR order because I know just how brutal and invasive running a code on someone can be. I have had to do it - even on people that I knew it would be an ultimately futile effort. Because I believe that full code people should be given their best chance, I'll do it all at full-speed, even if it'll be futile. It's not my place to judge someone else's wishes. I'm even willing to provide massive amounts of care to DNR patients because that doesn't mean "do not treat."
Since we all will die, our job isn't so much to save lives, but rather to extend quality of life. Everyone is different, and because of that, the time that our quality of life becomes more important than the quantity of it will be different for everyone.
I think of it like this: our job in a code is to provide someone a good shove toward life. If they're able to respond, good. If not, let them go as peacefully as possible, and comfort the family. They're the patient too.
- 3Dec 7, '12 by Indy BIt seems that a lot of discussion revolves around the family's wishes. One of the most interesting questions I heard while interviewing was, "Do you think family should be present for a code?" My answer was a resounding "YES!" Education is key, if family knew what truly went into a full code, they might not brush off the DNR so quickly. I can't support NurseCard's statement enough, DNR is NOT Do Not Treat.
- 0Dec 7, '12 by MusicEMTQuote from BrandonLPNIn EMS if they are clearly dead the paramedics can call them on the spot (ie Rigor mortis or decapitation or whatevs)What about the nurse who comes across the full code pt in LTC who's clearly been dead for a couple hours? Is it "unethical" to forgo a code in that case? I mean, come on people, at some point all we're doing is desecrating a dead body.
there is a saying in EMS: they are not dead till they are cold and dead
i dont know how it is in LTC.. i would assume if they are clearly dead (cold and dead for a few hours) you dont need to start code measures?
- 2Dec 7, '12 by subeeQuote from RFarleyRNI disagree. The fact is that only 15% of inpatient codes survive. The original OP described a situation of a patient so frail that the ribs were crushed during the codes. EVERY patient's situation is different and deserves a decision based on our intellectual and compassion skills.Well I hope you are my nurse when I am old and cannot make decisions for myself. As an RN, and former hospice nurse, I am so apalled by this, I can hardly speak!! This man had the right as a patient to have every effort initiated to save his life. We are not to play God with anyone elses life. I would hate to stand before the Lord and face judgement for actions such as your co-workers. Horrible situation.
- 3Dec 7, '12 by Esme12 Senior ModeratorQuote from redhead_NURSE98!I have always HATED this attitude DNR does NOT mean do not treat. I had a personal experience with this recently with my brother in law and being transferred to ICU when hospitalized when the ICU nurses had the unmitigated gall to talk to my sister about her husband "taking up an ICU bed". Just because we didn't want him coded doesn't mean we didn't want treatment to stop the immediate threat or that he should suffer because a DNR in ICU takes up valuable space. My BIL was YOUNG....I was so angry it made me want to spit nails.The problem I have with these is that I've seen physicians just see these documents and say "oh they're DNR." Um NO. Therefore I will not be filling one out for quite awhile.
Even a DNR can require care befitting an ICU and you know what....sometimes a family just isn't ready to say good bye.
But this is off topic...sorry
- 2Dec 7, '12 by PMFB-RNQuote from KelRN215*** Seems very premature to me. I regularly see young trauma patients who get both a feeding tube and a trach who go on to lead totaly normal and high qualiety lives with nothing but a few scars to show for their experiences.I am only 28 but I have already told my family that under no circumstances would I want a feeding tube or a trach. If they were to ever disregard my wishes and insist on futile heroic measures well, then I can only hope that there's an after life so I can come back and haunt the hell out of them.