The Slow Code: Justified?

During a 'slow code,' the members of the healthcare team are purposely not putting forth their full efforts to resuscitate the patient by moving with no apparent sense of urgency while performing CPR. Do situations arise where a slow code would ever be justified? Nurses Safety Article

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Music in My Heart

1 Article; 4,109 Posts

Specializes in being a Credible Source.

As someone who plans to have DNR tattooed across my chest, I agree whole-heartedly with TheCommuter... you either run the code or you don't. If you're going to code the patient then you follow the ACLS protocols until the code is called... period...

That said, MDs need to do a much better job on educating people what it means to code somebody and just how poor are the chances for an intact discharge from the ICU. I feel badly for what we do to these folks sometimes and I think many more people would choose the DNR option if they really understood the choice.

Bottom line, though... the only person who gets to decide the code status of the patient is the patient themselves (or their proxy) and you either code them or you don't... no show-code, slow-code, etc.

I have used the term show-code to describe our efforts but I've meant that we've run an obviously futile code longer than warranted primarily so the family would know that everything possible was done to save their loved one... especially on kids.

BrandonLPN, LPN

3,358 Posts

See, though, your talk about central lines and saving kids leads me to believe that you don't work in LTC. It's a different reality when you do. There's no "code team" or IV meds or stuff like that. There's just me shoving a board under the dead body of a 90 year old man and then proceeding to pulverize his rib cage. That's it. Should I *really* go all out on every full code resident without exception? Not everything is so black and white.

Music in My Heart

1 Article; 4,109 Posts

Specializes in being a Credible Source.

Brandon, I'm now in a mega-ED so it is different for sure.

Prior to that, though, I was in a rural hospital and had experiences more similar to yours.

I suppose if there is no crash cart and you must simply rely on EMS, there's no point... still, if the patient is not a DNR or "no CPR" then I think we're ethically bound to beat the snot out of them even though there's very little chance they'll even make it to the ICU and ZERO chance that they will ever get out.

I've walked away from my share of codes with a heavy heart at what we've done to this person in their last minutes of life. One can't be unchanged by the first time you bust every rib some 90-lb waif of an LOL/LAM has.

If you're going to bust 'em up anyway, you may as well do it early and correctly... otherwise don't do it at all.

The problem is with our society's refusal to openly and easily discuss end-of-life decisions... remember how quickly the 'death panel' mantra was rolled out, and how many bought into it?

Specializes in Emergency Department.
*** The DNR order is irrelevent until the person dies. We don't code people who are alive, at least I don't.

I

*** What therapies are resricted when a patient is DNR? None I am aware of, with the possible exception of intubation, (depending on if you are in a DNR vs DNR/DNI faciliety) until after they die.

*** Yes I agree, however I see this as a symptom of the much broader problem of a society with unrealistic expecations combined with denial of realiety.

DNR also comes into play in a pre-arrest situation where you have to work to prevent a code. In the pre-arrest situation, it means no intubation, no pacing, and no cardiotonic drugs. Everything else is fair game to use. That includes CPAP and Bi-Level PAP. In other words, if your patient is starting to have circulatory problems where they're no longer able to perfuse tissues, that may mean you have to start IV pressors if their fluid status is adequate. If their heart slows down or no longer pumps effectively to the point where enteral meds aren't keeping up... you've just hit your limit because you can't use TCP either.

Notice that I didn't say that fluid support to maintain adequate hydration/fluid status (aka IV) isn't allowed. IV antibiotics are totally OK under a DNR order. Notice that I didn't say that supplemental O2 isn't OK. Even bronchodilators are OK.

A DNR is very specific about what's not allowed. No CPR. No TCP. No intubation. No Assisted Ventilation. No cardiotonic drugs.

A POLST allows more options and covers a wider range of situations that go beyond the peri-arrest stuff and can even restrict things that aren't restricted with a DNR order.

And of course, a living will just allows pretty much the whole spectrum. People just have to actually read them.

bbuerke

36 Posts

Specializes in Oncology.

quote from akulahawk:

A DNR is very specific about what's not allowed. No CPR. No TCP. No intubation. No Assisted Ventilation. No cardiotonic drugs.

I don't know that this is universal yet. I know a lot of hospitals are moving to this model for definition of DNR, but I don't think all have caught up yet. Some people interpret DNR as no compressions, no intubation only, but meds and shocks/TCP are OK depending where the person falls in the ACLS protocol.

Would be interesting to see the differences between states/facilities.

quote from music in my heart:

still, if the patient is not a DNR or "no CPR" then I think we're ethically bound to beat the snot out of them even though there's very little chance they'll even make it to the ICU and ZERO chance that they will ever get out.

THIS*** is exactly what's wrong with end of life care in this country. It is the one area where we are, as you put it, ethically bound to provide substandard/ineffectual care. In all other areas of what we do we are ethically bound to provide the most effective, evidence based practice, but not here. This absolutely has to change, and as I said before, should come from the organizations/experts who drive practice through protocols and standards of care. It will only change if we change our protocols. Working in oncology I've worked with a few attendings who say, "when they go, call the code but page me too. I'll come over and pronounce them." That way we don't go on and on in a futile effort, and the family knows we tried. It's not a slow code per se, but maybe a "short code"? We still go all out, but at least someone has the good sense to put a stop to it at a reasonable point. I think that's the main problem with codes - they can go on indefinitely if you let them. Meanwhile the person's chances of meaningful recovery decrease with every passing minute. There really should be a time limit on those things.

catlvr

239 Posts

Specializes in Geriatrics, Hospice, Palliative Care.

I, too, work in a SNF and have run several codes (which usually means just CPR and AED, although a friend once pushed dextrose on someone dead from hypoglycemia - he was resuscitated). And while I absolutely hated doing it, I broke ribs on a patient, even though he was already quite chilly (a colleague's patient - she had never done CPR before and it was just the two of us, until EMS came and called it. I felt badly that this poor man was basically a learning experience.)

The codes on poor LOL/LOM with family members in denial of their prognosis, no matter how much education you do - those haunt me. I wonder if their spirit is in the room begging us to STOP abusing their corpse.

TheCommuter, BSN, RN

102 Articles; 27,612 Posts

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
I think that's the main problem with codes - they can go on indefinitely if you let them. Meanwhile the person's chances of meaningful recovery decrease with every passing minute. There really should be a time limit on those things.
Our local EMS service, which is contracted by the large city where I live, has a time limit of 30 minutes per internal policy. If the patient has not been resuscitated after 30 minutes of CPR (and there's no hope of resuscitation), they call it off and pronounce.

MunoRN, RN

8,058 Posts

Specializes in Critical Care.
still, if the patient is not a DNR or "no CPR" then I think we're ethically bound to beat the snot out of them even though there's very little chance they'll even make it to the ICU and ZERO chance that they will ever get out.

I think that's probably the root cause of the "slow code" phenomenon, one could also argue that we're ethically bound not to initiate CPR in some instances regardless of what an order happens to be. "Do no harm".

We don't have "slow codes" where I work, but we used to have "short codes". Recently though we've been more proactive on the palliative front and in those cases that at one time had been "short codes", we just make it clear ahead of time that what we will, and what we won't do.

PMFB-RN, RN

5,351 Posts

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.

A DNR is very specific about what's not allowed. No CPR. No TCP. No intubation. No Assisted Ventilation. No cardiotonic drugs

.

*** It depends. I have noticed that in Wisconsin where I live DRN means exactly what you say above. However over in MN where I work intubation is treated as a seperate issue. We will intubate a DNR patient if they are not also DNI. It says on their wrist band "DNR" or DNR/DNI" or "DNI".

PMFB-RN, RN

5,351 Posts

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
It 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.

*** For me it depends. If I believe we have no business codeing this patient I want the family at the bedside so they can see just how brutal it is and hopefully they will yell "STOP!". If on the other hand I think we have a good chance of saving this patient by coding them I kick the family out so I can concentrate.

bbuerke

36 Posts

Specializes in Oncology.
It says on their wrist band "DNR" or DNR/DNI" or "DNI".

How does that work? If someone stops breathing but has a pulse, unless you do something about it, eventually they will have no pulse. Are you supposed to just stand around and wait for the pulse to stop, then do compressions because they are not a "DNR" as well? I realize I'm being nit-picky, but this image just made me think of Peter Sellers in Murder By Death:

"Not breathing. No pulse. If condition does not change, he'll be dead!"

:roflmao:

CT Pixie, BSN, RN

3,723 Posts

In EMS if they are clearly dead the paramedics can call them on the spot (ie Rigor mortis or decapitation or whatevs)

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?

Nope, in LTC (at least here in my state) we HAVE to start codes if they are not listed as a DNR. Regardless of 'how' dead they are we still have to start code measures and continue until EMS arrives and takes over. (Luckily I never had a 'clearly' dead pt I had to code, but I did have to code a few that it killed me to do it). Now en route the EMS can call the hospital and give the info from there I'm not entirely sure if they can call it. I was an EMT and recall one code we responded to in a LTC. Now thinking about it, I don't recall seeing anyone from the LTC staff doing anything. EMS started the code from what I recall. (unless when the saw us coming in the door they stopped to allow us to take over and I just didn't notice it as it was my first EMS code) The patient was clearly dead and no amount of coding was going to bring her back. I did the compressions from the LTC to the hospital (less than 3 miles away).

EMS in my state can call them on the spot under certain circumstances such as rigor, decapitation and another which I can't recall at this minute.