A question of code status

fiestynurse · Feb 14, 2002

Yes, this is very common now with the introduction of "Advance Directives." We use to just write general terms, like "supportive care only." But, this was interpreted differently by various people and caused many problems. (lawsuits!) Now, it's broken down and much more specific. The patient and family have to decide what they want and don't want.

In your Health Care Advance Directive, you state your wishes about any aspect of your health care, including decisions about life-sustaining treatment, and choose a person to make and communicate these decisions for you.

toronto rn · Feb 14, 2002

This is such a contraversial area. Currently code status at my hospital is dependant on the particular Dr involved. Some have the gumption to address the issue head on and make a decision based on the pt condition and previous health status. Others allow the family to decide without the family having adequate information to make this decision. Others will override the patients decision to be a no code regardless of the documentation that is on the patient chart. A very frustrating situation. We have had to do CPR on end stage Ca patients who's bones break as you compress them because the family have not had proper counselling and information sharing. Some cultures believe that not to intervene is akin to murder. Several years ago it was only the doctor that made the decisions re code status. Now the public is demanding the right to informed decision making and rightly so, however, with that ability comes a mess of opinions, and options often prolonging time to make decisions. This often result in ICU beds being tied up for extended periods with patients who are not viable. The ethics involved in this type of decision making are not easily addressed. I don't think it would be right to have a standard code policy for all patients. Individual cases must be addressed by the individual desires of the pt/family and the status must be allowed to be flexible to a degree. I may have an opinion about the appropriateness of the patients code status but does my opinion have any place in the decision making of the family? No easy answers here.

wrightgd · Feb 14, 2002

When I worked ICU, there were a couple of docs who would write for a "chemical code".... That is, meds only, no chest compressions or electric shock, tubes, ect... Almost always inefective, but it was a good choice for most of those patients who were already fragile. Why put someone through the trauma of a "full code", often many times during their last days, only to extend their suffering.

GDW

CATHYW · Feb 14, 2002

I like the sound of a "chemical code." As you said, for the patients that are so fragile that compressions and intubation would cause further injury, it is a good compromise. Plus, if someone bradys down or blocks, or runs PVC's or tachyarrythmias, meds might help.

There is also the insult of doing multiple invasive procedures to an already suffering, not-likely-to-be-viable person. why put them through more? I have seen (as have we all) families that want everything done for great-grandma, who is 90 years old and has been an invalid for years. :rolleyes: :eek: Why put the poor soul through anything else?

If the person is relatively young or a victim of trauma, or something similar, then I would say that yes, let's pull out all of the stops and see what we can do for this person. All of my family knows that I do not want to be on a vent longer than 2 weeks (anything that can be reversed can be done during that time, I think). If things don't look good, unplug the vent, call the code, or whatever, and call LifeLink to come get whatever usable parts they want-I won't be needing them anymore, and I'll be in a far better place.:) :) My opinion only...

VickyRN, MSN, DNP, RN · Feb 14, 2002

I am of the opinion that a nurse ought to be given the position of Grief Counselor and review each "case" that comes through the door of our ICU. Patients and families should be plainly told what "full code" and "no code" means [also what it REALLY means when you say you want EVERYTHING DONE... most people don't have a clue..]. All of these legal terms are baffling to most families in a time of crisis and they REALLY need to be educated on a level they can understand, all the while building trust and empathy. I think a lot of patients (and their families--especially people of color--) truly believe that "no code" means "no care." They're suspicious of health care workers anyway and want their loved one to have the best of care, so they naturally demand that everything possible be done!!! Sadly, most don't realize until it's too late, how incredibly cruel and taxing such measures can be. This is a very difficult subject, but PEOPLE NEED TO BE INFORMED.

fiestynurse · Feb 14, 2002

Federal law mandates that all patients admitted to health care facilities who receive Medicare or Medicaid funding receive information about advance directives upon admission. Unfortunately, some facilities interpret this as merely asking whether the patient has an advance directive or if he'd like to prepare one, then giving him literature to read; no one's available to help him sort through the legal jargon or answer his questions.

Without help to understand the nuances involved in preparing an advance directive, the patient may execute one that isn't much use when needed. This is where physicians and nurses can really be proactive. Make sure that your patients understand how important this is and be ready to answer any questions that they might have.

VickyRN, MSN, DNP, RN · Feb 14, 2002

I genuinely try. Oftentimes, even with literature in hand (written on a 5th grade level), most patients and families truly do not understand. Doctors often will not broach the subject. Sometimes they will harriedly spit out an explanation that patients/families truly do not comprehend but are too embarrassed to seek clarification. This is often a time of crisis, maybe the worse crisis they have ever faced, so people are so emotionally preoccupied. I try to be sensitive, gently talk to patients and families in a manner they can understand, especially the meaning of the term "full code." Even with literature in hand, most patients still do not have a clue what that term really means. IF I have the time, I will often pull the family out in the corridor, out of hearing distance of the patient (even if disoriented or comatose) and ask them plainly if "mamma" or "pappa" stops breathing or their heart stops beating, do you want a tube put down their throat, them put on a ventilator, shocked, chest compressions (forceful enough to break ribs--most people don't realize this), needles stuck in their body, medications and fluids pushed in. Once I have gently but truthfully informed pt's and families, I have no problem respecting their wishes. Sometimes, I don't have the time. A lot of patients and families I see falling through the cracks. This is where the position of Grief Counselor would be so marvelous.

fiestynurse · Feb 14, 2002

Ideally, it should be discussed at the clinic level, long before a crisis occurs. It should be discussed prior to any major surgery, before giving birth, and with any patient that has a chronic illness, such as heart disease. A copy of the advance directive should be put on the front of the patient's chart.

Here are key points to tell your patient:

* Spelling out what treatments he'd want in certain circumstances can save him and his family grief later.

* An advance directive goes into effect only if he has a terminal illness and loses his decision-making capacity.

* After he's executed an advance directive, he can change it at any time.

* If he grants someone durable power of attorney for health care, he should tell that person his preferences.

CEN35 · Feb 14, 2002

well for us, we have one sheet. there are two options the first being, complete dnr (nothing done), and the second which is a "partial dnr". under the partial dnr, there are seperate areas that treatment will be limited too. 1) cpr, 2) intubation and mechanical ventilation, 3) antiarrythmics, 4) vasopressors, 5) defibrillation/synchronization, 6, 7 & 8) other. the other can be used for specifcs, or requests by the family. (i.e. tube feedings, etc)

just me :)

gpip · Feb 15, 2002

thanks everyone for your imput. we do chem codes also. The reasoning others gave like the patient is too fragile to be intubated or have chest compressions done is a little suspect to me. the reason I feel this way is according to our intensivist you are doing nothing for the patient if you are giving them but not doing chest compressions to circulate them?

hapeewendy · Feb 15, 2002

I agree with many of you that the education for families re dnr status etc is what is lacking

these families are unable to make educated decisions, I've seen it personally where the dr waltzes in , gives a grim report on patient progress and it is just decided that the pt will be DNR, unfortunately DNR seems to be a way for many ppl to just let ppl die by the landslide it seems, where I work many drs use the term "well the pt is DNR what do you want me to do for them?"

DNR technically speaking means, should I die, do not make any attempts/heroics to bring me back to life, the term does not mean do not react/respond

to any situation.

for example last nite I got an admission from EMERG, very sick, very old , poor prognosis etc etc, u know the clinical details , however, the patient came up on a rebreather type set up to which she kept unhooking the entire set up, I queried RT as to whether we could try another set up, despite the fact she is DNR she shouldnt be starving for every single breath/bit of air, we should try to make her as comfortable as possible

right? well RT came up onto the floor *****ing and moaning about why we are doing so much for pts who are DNR. I gently reminded him that DNR does not mean do not treat any pertinent issues that may arise such as oxygenation needs and he just huffed and kind of said that the dr had told him that the pt wouldnt live til morning anyway

is it just me or do you guys see ppl hiding behind this DNR thing just as an excuse to idle and do nothing?

its a shame that we cant respect the patients choice not to be resuscitated and have turned it into , "okay no extreme measures, so lets just not bother to do anything"

its not everyone, ive worked with many great professionals that have tried to ease the transition of a dying patient the best ways possible

its just disheartening to me that we are not educating families properly as to what all this means and that DNR has somehow become a rationale for slacking off on ones responsibilities to their patient.