The Slow Code - page 9

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... Read More

  1. Visit  AnonRNC profile page
    4
    This is a very interesting topic and a fabulous discussion. I have a couple of things to add.

    In 14 years of NICU/Peds nursing (plus 4 as a CNA), I have never seen a "slow code."

    However, in the NICU, we do sometimes have "limited codes" and in those cases the do's and dont's are clearly in the MD order. For example, a baby with overwhelming sepsis and metabolic acidosis on full ventilator support, fluid resuscitation, sodium bicarb, antibiotics, and pressors to maintain BP...the order (after discussion w/family about "futility of care") was no compressions if his heart rate slowed on its own. On the other hand, if the patient experienced bradycardia due to accidental extubation, we could do compressions while reintubating. And that plan of care crystallized something for me:

    (1st point) CPR does NOT 'bring them back.' What CPR DOES do is buy you some time while you correct the problem that caused the arrest.
    Read that again; it's important. In the case of overwhelming sepsis and acidosis, there wasn't anything more we could do to correct the problem (we'd already given everything we had to fight infection & correct acid/base balance), so chest compressions would not be indicated. In the case of accidental extubation, we could reintubate and "fix" the problem, so chest compressions would be indicated.

    (2nd point) It is vital to recognize that if CPR does happen to 'bring them back' (to spontaneous circulation - i.e. a pulse), that survival to discharge rates are quite low. That interim time results in huge financial charges, pain and suffering for the patient, and emotional distress for the family.

    (3rd point) Families don't usually REALLY know what they're saying when they say yes or no to resuscitation. I think we overburden them with the decision making. We are asking them to do something extremely difficult; we're asking them to say "Let my Mother/Husband/Daughter/Lover die." I think we would be wiser to make the decisions ourselves - in most cases. "Your father has had a debilitating stroke from which he will not recover his ability to speak, eat, walk, or talk. He probably does not recognize you or understand anything happening to him. Because of his co-morbidities he is now in multi-system organ failure. Despite our interventions, eventually this will cause his heart to stop and he will die. Would you like to be with him at that time? Would you like spiritual support? How can we help you through this sad and difficult time?"

    (4th point) We need to have more conversations around the topic of "futility of care," rather than just pressing on with treatment after treatment.

    (5th point) Advance directives (living wills) can help. Nurse know better: we should ALL have one. Here is one of the best I've ever found. http://compassionwa.org/wp-content/u...web-secure.pdf Don't worry that it's supposed to be for Washington State because - GUESS WHAT - advance directives are NOT legally binding. Therefore, advance directives should be coupled with CONVERSATIONS with your loved ones. And I heartily agree with the earlier poster who made a friend (not her spouse) her DPOA.

    (Stepping off soapbox - thanks for listening)
    liebling5, GrnTea, bbuerke, and 1 other like this.
  2. Visit  somenurse profile page
    2
    Quote from redhead_NURSE98!
    Do you all ever wonder if these wishes are financially motivated? Like the deadbeat kids who "take care of" their parents in the parents' home, and cash their SS checks to "provide care" for them? I sometimes wonder when I meet these people.

    I wouldn't know, i kinda doubt it, it takes a pretty cold person to allow mom to suffer so you can have her check,
    shiver!!! ouch.
    but, more often,
    in the times i've assisted some doc helping a family D/C the full code order, or agree to remove the vent, etc, (often done in sort of family-conference kind of set up)
    it seems to me, like 70% of the time,
    it is the long distance relative who is fighting tooth and nail to keep the full code order, or the tubefeed/vent, etc, all going.

    The stand-by kid (when i say kid, this could be the adult child in their 50s)
    who has cared daily for the person, who has seen the decline day by day, living nearby the now dying person,
    is usually (not always, but usually) far far more willing to realize, "Yeah, Mom is too sick to keep coding her, and her quality of life is mostly just pain and confusion nowadays."

    i can just about pick out the long distance kid in the group. I never know if it is cuz they are so far away, they don't realize how sick 'Mom' is, or is it guilt (deserved or UNdeserved) or is it some ache for more time that kid needs/wants to catch up lost time, (?)
    but,
    imo, it's so often, that long distance relative who wants to keep on coding, keep the vent on, and last to realize, that Mom is sliding into home plate now.

    of course, as we all know,
    every family is a unique mosaic, and there's no rule. Such an inside-out, vulnerable time for any person....living wills can sometimes be such a comfort in those times, imo.

    but, i swear, i can often pick out that long-distance kid in the group.
    PMFB-RN and Altra like this.
  3. Visit  Anoetos profile page
    1
    Quote from redhead_NURSE98!
    Do you all ever wonder if these wishes are financially motivated? Like the deadbeat kids who "take care of" their parents in the parents' home, and cash their SS checks to "provide care" for them? I sometimes wonder when I meet these people.
    I don't wonder at all. I am quite certain it happens a lot.

    In fact, I am confident that I have witnessed it.
    MomRN0913 likes this.
  4. Visit  PMFB-RN profile page
    0
    Quote from AnonRNC
    (3rd point) Families don't usually REALLY know what they're saying when they say yes or no to resuscitation. I think we overburden them with the decision making. We are asking them to do something extremely difficult; we're asking them to say "Let my Mother/Husband/Daughter/Lover die." I think we would be wiser to make the decisions ourselves - in most cases.
    *** I agee, if by "we" you mean nurses. Physicians would be only marginaly better than families. Lot's of them do not want to make decisions either.
  5. Visit  JoyfulNurseLPN profile page
    0
    This article gave me chills. I have heard about ''slow codes'' before but
    I wrongfully assumed they were some sort of urban legend or medical myth
    that had existed for eons but weren't really part of reality.

    The behavior of the other staff is particularly disturbing and frankly, unethical.

    I was recently informed that one of my prior co-workers at a LTC facility arrived
    on her unit only to discover a patient had passed away and was cool to the touch.

    The patient was a full code but CPR was not initiated. Both the supervising RN
    and that nurse were fired on the spot.
  6. Visit  PMFB-RN profile page
    0
    Quote from JoyfulNurseLPN
    The behavior of the other staff is particularly disturbing and frankly, unethical.
    *** What behavior do you find disterbing and unethical?
  7. Visit  JoyfulNurseLPN profile page
    0
    Quote from PMFB-RN
    *** What behavior do you find disterbing and unethical?
    To quote the article "This clinically dead man was a full code, yet the multiple people in the room were moving with a disturbingly unhurried pace.", "A nurse with more than 20 years of experience glanced at me with a smile and sternly said, “Give it up! Don’t waste your energy! Wait until EMS gets here, then act as if you’re doing something in front of them!” She ended her statement with a quiet giggle as the house supervisor stood over me, grinned, and nodded in agreement."

    And finally, most disturbing of all, "Approximately 30 seconds before EMS staff entered the room, my coworkers began putting on the show and pretended to exert an all-out effort to save the patient (a.k.a. the ‘show code‘ or ‘Hollywood code‘).''

    Those things I found particularly disturbing, and unethical. To stand by while someone who is a full code and do nothing, then encourage someone who is trying to help the patient in duress is in my mind cause for professional misconduct. Then, to behave after the notified EMS staff arrives as if you have been contributing to the care of the patient in duress is frankly alarming and highly disturbing in my opinion.

    You don't find that disturbing?
  8. Visit  TheCommuter profile page
    0
    Quote from JoyfulNurseLPN
    You don't find that disturbing?
    You're going to receive a mixture of opinions on this issue. Based on the content of the 100+ responses, apparently not everyone is disturbed by slow codes.
  9. Visit  PMFB-RN profile page
    0
    Quote from JoyfulNurseLPN
    To quote the article "This clinically dead man was a full code, yet the multiple people in the room were moving with a disturbingly unhurried pace.", "A nurse with more than 20 years of experience glanced at me with a smile and sternly said, “Give it up! Don’t waste your energy! Wait until EMS gets here, then act as if you’re doing something in front of them!” She ended her statement with a quiet giggle as the house supervisor stood over me, grinned, and nodded in agreement."

    And finally, most disturbing of all, "Approximately 30 seconds before EMS staff entered the room, my coworkers began putting on the show and pretended to exert an all-out effort to save the patient (a.k.a. the ‘show code‘ or ‘Hollywood code‘).''

    Those things I found particularly disturbing, and unethical. To stand by while someone who is a full code and do nothing, then encourage someone who is trying to help the patient in duress is in my mind cause for professional misconduct. Then, to behave after the notified EMS staff arrives as if you have been contributing to the care of the patient in duress is frankly alarming and highly disturbing in my opinion.

    You don't find that disturbing?
    *** There has been a lot of discussion in this topic and I didn't realize you were refering to the OP. Standing by and doing nothing when a person is full code may or may not be disterbing and unethical depending on the circumstances. For example I will not go aginst a patients informed decision to be DNR just cause the out of town adult child, or estranged wife changed the code status after the patient could no longer speak for themselves.
    Misleading EMS I do find disturbing, not coding a person who made an informed decision to be full code I also find disterbing and unethical.
  10. Visit  PMFB-RN profile page
    0
    Quote from AnonRNC
    This is a very interesting topic and a fabulous discussion. I have a couple of things to add.

    In 14 years of NICU/Peds nursing (plus 4 as a CNA), I have never seen a "slow code."
    *** Neither have I seen a slow code on a peds patient in 18 years of nursing.
  11. Visit  somenurse profile page
    2
    Quote from PMFB-RN
    *** Neither have I seen a slow code on a peds patient in 18 years of nursing.


    me either, and it's a rare pedi code that isn't followed by a weeping staff, too. Whether they weep together, or go off into a bathroom to weep, lotta staff weeps when we lose a child.
    AnonRNC and PMFB-RN like this.
  12. Visit  JoyfulNurseLPN profile page
    0
    Oh, I absolutely agree with you Commuter. Some people think it's a dignity
    issue to allow someone to die peacefully where death is obviously imminent, I
    agree to an extent but I don't agree with standing around and putting on a big
    charade and then pretending that you've been doing something the whole time
    when other staff arrives to tend to the patient. I think that's redonculous.

    I agree also that it's kind of a grey area, and I sometimes would be hesitant
    to perform CPR on a frail little elderly person who has obviously passed but
    has a standing full code order - but I've also heard of people getting into
    really big trouble for not helping the patient if they are a full code.
  13. Visit  JoyfulNurseLPN profile page
    0
    Quote from PMFB-RN
    *** There has been a lot of discussion in this topic and I didn't realize you were refering to the OP. Standing by and doing nothing when a person is full code may or may not be disterbing and unethical depending on the circumstances. For example I will not go aginst a patients informed decision to be DNR just cause the out of town adult child, or estranged wife changed the code status after the patient could no longer speak for themselves.
    Misleading EMS I do find disturbing, not coding a person who made an informed decision to be full code I also find disterbing and unethical.
    heh, I jumped in really late as I've just discovered this message board, so I responded really late to the OP.

    I also agree, an informed decision made by a patient to be a DNR should never be gone against especially if a family decides later it's in their best interest to be a full code, I would think that sounds
    like there is some other motive to keep the patient alive at that point.

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