The Slow Code - page 9

by TheCommuter 25,885 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


  1. 0
    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
    .
    *** 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".
  2. 1
    Quote from Indy B
    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.
    hiddencatRN likes this.
  3. 0
    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!"

  4. 0
    Quote from MusicEMT
    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.
  5. 1
    Quote from Jean Marie46514
    above quote is referring to a living will.
    Your last sentence there, leads me to believe, that you yourself view living wills, as being equated to a self- full code order,(? not sure, but, seems like that is what you meant??)

    Some ppl also think a living will = self DNR order.
    I view a living will as being subject to interpretation by some ignorant physician (generally one not educated in the United States) as "oh they have a living will? They're DNR." Seriously.

    WHATEVER YOU DO, DON'T READ THE DOCUMENT, DOC!
    somenurse likes this.
  6. 0
    Quote from redhead_NURSE98!
    I view a living will as being subject to interpretation by some ignorant physician (generally one not educated in the United States) as "oh they have a living will? They're DNR." Seriously.

    WHATEVER YOU DO, DON'T READ THE DOCUMENT, DOC!

    yes, that could happen. With an actual living will, though, the family could, argue against what the doc has ordered (might involve getting new doc). MIght or might not be, the wisest, most compassionate thing to do, undo an DNR order, but, if the pt's living will stated they wanted to be full code, in most states, the family could use that to get a DNR undone, and have pt put back on full code status.

    I can't quite recall ever seeing a doc order a DNR on a patient that we nurses thought was a crazy order. Might have happened, we can never say never...
    but, i can't recall ever seeing that...

    I've seen docs who refuse to make a pt a DNR, even as the pt is most obviously approaching the day that will become very pertinent....
    but, the other way around, can't recall it.

    Imo, is great idea to have a medical POA, too.
  7. 0
    I had one patient who had a lawyer draw up legal papers that were signed by both the patient, a witness and the lawyer regarding her wishes to be DNR/DNI as well as a directed for no tube feeds, invasive procedures etc . The papers were in her chart under the Directives section.

    However, when I looked at her advanced directives in the computer it said FULL CODE signed by the doctor and her husband (POA/medical proxy). Not only was she a full code in the LTC, she also had a feeding tube placed a couple of years prior to me being employed there. I questioned the full code order as it was the direct opposite of what the paper said. I was informed that the husband had changed her to a full code and that he wanted everything done to keep her alive. Paper work in the chart (the DNR or full code paperwork we use) was signed and dated after the DNR paper. I was told because he was her proxy he had the right to change the status. She was indeed a full code. I always shook my head..the woman knew what she wanted and had the legal papers drawn up before she became incapicitated and yet her wishes were tossed to the side by her husband and he was doing everything she specifically in the papers that she did NOT want. How is that even legal? what's the point of having all the papers drawn up, informing everyone of your decision etc and yet it can be changed when you ARE no longer able to make decisions regarding your healthcare?!

    I have my health care directives with my lawyer, as well as copies that my mom, husband, best friend and sister have. I tell anyone who will listen my wishes. I even have a copy i keep in my purse. Hoping and praying my husband follows it to the letter should it ever be needed. And if he waffles, I KNOW my best friend will advocate for me and my wishes. Upon thinking about it, I just may have her become my medical proxy. Just always assumed the NOK would have final say regardless of someone else having the proxy.
  8. 0
    Quote from CT Pixie
    I had one patient who had a lawyer draw up legal papers that were signed by both the patient, a witness and the lawyer regarding her wishes to be DNR/DNI as well as a directed for no tube feeds, invasive procedures etc . The papers were in her chart under the Directives section.

    However, when I looked at her advanced directives in the computer it said FULL CODE signed by the doctor and her husband (POA/medical proxy). Not only was she a full code in the LTC, she also had a feeding tube placed a couple of years prior to me being employed there. I questioned the full code order as it was the direct opposite of what the paper said. I was informed that the husband had changed her to a full code and that he wanted everything done to keep her alive. Paper work in the chart (the DNR or full code paperwork we use) was signed and dated after the DNR paper. I was told because he was her proxy he had the right to change the status. She was indeed a full code. I always shook my head..the woman knew what she wanted and had the legal papers drawn up before she became incapicitated and yet her wishes were tossed to the side by her husband and he was doing everything she specifically in the papers that she did NOT want. How is that even legal? what's the point of having all the papers drawn up, informing everyone of your decision etc and yet it can be changed when you ARE no longer able to make decisions regarding your healthcare?!

    I have my health care directives with my lawyer, as well as copies that my mom, husband, best friend and sister have. I tell anyone who will listen my wishes. I even have a copy i keep in my purse. Hoping and praying my husband follows it to the letter should it ever be needed. And if he waffles, I KNOW my best friend will advocate for me and my wishes. Upon thinking about it, I just may have her become my medical proxy. Just always assumed the NOK would have final say regardless of someone else having the proxy.


    oh that's so sad. this can vary state to state, a family overriding a living will.
    That's just exactly what my family would do, too, so i got a medical POA outside the family (my best pal, who is very assertive, yet, would also be compassionate in helping my family accept it all)

    also, i told my family that Bev is my medical POA. Used to be my guy, til i saw how long he prolonged agreeing it was time to put down our beloved dog (who could no longer even walk and was in pain). THAT'S when i realized, he'd be even worse "putting me down", so i removed him from my POA. He understood, and was maybe even very slightly relieved, as he is no good at such things, and some doc or nurse could easily manipulate him around, he'd be putty, in THAT situation.

    My point there is, a person's medical POA does NOT have to be their next of kin.
    Last edit by somenurse on Dec 8, '12
  9. 1
    Quote from catlvr
    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.
    Yeah the ones whose families want us to do everything while they pray every day that God will "take me home". Painful. Not entirely convinced that a slow code is a terrible ethical violation in those cases.

    Our health region is moving away from the language of DNR altogether. We now go through advanced orders as part of the admitting process (if we can get them to do it) with patients in essence writing their own orders. There are sections pertaining to CPR, treatments, antibiotics, and nutrition specifically. They are also encouraged to designate a proxy. This paperwork follows them wherever they go in the region and can be changed at any time they want. We've gone this route because of many of the problems brought up in this thread (living wills being in legalese and disregarded, lost because they are in a safety deposit box somewhere, Doctors who don't treat etc.)
    Last edit by lemur00 on Dec 8, '12
    somenurse likes this.
  10. 0
    This is a little off topic, but ive also seen- RN may pronounce. So in that case, if theyre a full code, you'd perform until the rn called it, right? No ems, physician needed at that time?
    Or is it only with a DNR that it would say RN may pronounce? Im sorry, im starting in a ltc facility this week so i thought id ask. Please feel free to correct me if im wrong! Thanks!!


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