Can a nurse refuse to participate in a code?

[wooh]

I'm sure many of us have had patients that we felt it was just torture to code the person, but for whatever reason, the patient wasn't DNR.

We can refuse to hang blood for religious reasons.

We can refuse to participate in an abortion for ethical/religious reasons.

Can we similarly refuse to participate in a code?

ETA: Without getting fired/violating our nurse practice act/getting in some sort of trouble...

[leslie :-D]

You may not feel that a code is ethical, but if the PATIENT states in his/her advanced directives that he or she wants to resuscitated, who are you to say otherwise, even if it goes against your personal beliefs?

yes, it'd be highly unethical to disregard a pt's wishes, even if the nurse personally/morally disagrees with it.

afterall, we ARE supposed to be their advocates.

but it becomes much grayer if you know the pt doesn't want to be rescusitated, and a code is called anyways.

this happens all too often as well.

and so, should the nurse have to participate in a code knowing his/her pt didn't want it?

i don't know the answer, and i could see the nurse being terminated because of it.

but at the end of the day, i could also see the nurse being vindicated in a court of law...

since the nurse was acting beneficently.

we need to choose our battles wisely...

and be prepared for undesired consequences as well.

leslie

[NicuGal, MSN, RN]

We deal with this every day in NICU. When you have that 22 weeker with a massive head bleed, sepsis, renal shut down, etc but the family wants everything done, well you do it. If you we're assigned that kid and you refused to code him then you better be prepared to be punished. This is part of your job, and you do it and do your best in that situation for that patient and family.

[evolvingrn, BSN, RN]

No you can not, even a slow code is unethical. As nurse we support Patient autonomy. some times pts make stupids choices, but that is their choice to make , not yours.

[wooh, BSN, RN]

I'm not asking if I can say, "We aren't coding this patient." That would be obviously breaking all sorts of rules/regulations/laws/common sense.

Yes, I know the options of ethics committees, etc.

But, I can refuse to give blood if I'm a JW. I can refuse to participate in an abortion.

Can I similarly refuse to participate in a code?

NOT can I block the door and prevent anyone else from doing it or write DNR on a chart when nobody is looking.

[jadelpn, LPN, EMT-B]

The "paperwork" that says what you are/are not willing to participate in does have a few lines about other procedures that you are morally/ethically/religiously against participating in. Certainly your right. But then I would think it would give the hospital the right to dissmiss you based on those answers, and if they do not follow your job description.

I beleive that a nurse has a duty to act. No one can anticipate a code situation, therefore, a "plan b" would have to be put into place, which I am not sure can happen. Hence why I am not sure that a hospital would keep employed a nurse whose belief system is not in tune with coding a patient. But I would most certainly ask my malpractice insurance people.

The time to discuss it would be before it happens. To not participate when the expectation is that you should, could be a huge issue.

This is an awesome question. But my rambling answer makes little sense. LOL Bottom line--If you are objected to any code, then fill out paperwork and inform. If you are objected to just certain codes in certain situations, then that is different, and you need to think about how your duty to act could affect this.

You are an experienced nurse. You know it is not always feasible to step back and let others code and not participate. But I am not judging that decision, as it is intensely personal. I would just be sure you cover yourself, just as someone who will not participate in blood transfusions or abortions (or any other personal belief system that precludes participation).

[KelRN215, BSN, RN]

Since I am also a pedi nurse, I will offer my point of view from that perspective.

Sometimes kids are dying. We know they are dying and whether we code them or not, they are going to die. Sometimes no matter how many conversations are had with the parents they refuse to believe it and refuse to sign the DNR. I've seen parents convinced the God was going to swoop in at the very last minute to save their brain dead child. I've had conversations with MDs and other nurses as to "what would we do if this kid coded before we got the parents to agree to the DNR?" And everyone was on the same page that we would not code the patient. I've seen cases where parents wanted a child coded/everything done and the team stepped in and said "your child is brain dead and we are withdrawing support."

In my experience, way too many people show up to a code so if a nurse had some kind of particular objections to coding this patient, I think it would be possible for her to hang back and not participate without anyone else noticing.

[wannabecnl]

The tough part is that this is a case-by-case situation, unlike issues that are part of a nurse's religious or other beliefs that are essentially permanent. Someone opposed to blood transfusions isn't making a decision with each case whether to participate or not--they're just not going to. I'd call that a moral issue, whereas what you're talking about is more of an ethical issue. I agree with the posters who have recommended talking to the ethics committee at your hospital when a potential situation like this arises, because you might end up being the person who has to decide whether to call the code team, not just participating in it.

Also, even in cases of religious "opting out," nurses still cannot abandon their patients (i.e., if you won't provide the care, you have to find someone else to provide it). I don't know what that looks like in terms of blood transfusions or abortions, but in the case of a code, if you're in there and are able to assist and are needed and won't do it, that's pretty tough to defend. Not that I don't agree that there are cases where a code is just cruel, but I think you'd be in a heap of trouble.

Between this discussion and recently losing a family member who had not made her wishes known to anyone, I encourage everyone to get their wishes down on paper and discuss them with their kids, spouse, friends, and doctors!!!!

[evolvingrn, BSN, RN]

I am horrified at the ped nurse saying you will make that choice for a family. i am a former hospice nurse...........i "get' it truly i do . i have sent people from hospice to the icu......no joke....because they wanted to be kept alive (yes you can be a full code on hospice) . Do i agree with it? no. do I honor it? yes because that is my responsibility. if an ethics committee arrives at a decision and families are informed and have chance to appeal..........no prob. but any other reason .......no way. why would you put yourself at risk. sure you can 'go to the bathroom' during the code. but i certainly would never be so brazen to verbalize something like that. What we can do is educate families about the signs of decline we are seeing. talk about the discomfort of cpr and its low probability of sustaining life much longer. there is actually a video out there that a MD used to show DNR weary families. EDUCATE EDUCATE , EDUCATE , but always respect patient autonomy.

for the Jehovah witness nurse...........I have never worked with one. but i don't work on a unit that would be okay with them never getting pts that need blood................a nurse is providing medical care. its about the pt....not you. go in to home health are nursing home care if that is what you need to do.

[amoLucia]

I think you're standing on that proverbial slippery slope. Like many of us out there, we all don't agree with the course of action taken on many cases. But where do we draw the line???

An end-stage metastatic cancer pt who cries, "I just want to die" and then refuses to eat. A decision is made by family & MD to insert a GT with enteral feedings. Do you NOT give him his tube feedings? Family is pushing for extensive surgery which will only treat, not cure. Do you NOT do post-op wound care? Sophisticated IV care? What do you do????

We provide care - but not a pick & choose like from a menu's column 1 & column 2.

While I don't agree with the blood refusals of Jehovah Witness pts, I have adamantly supported their right to refuse - it's religion, theirs.

If I were anti-abortion, I certainly would not have a job with Planned Parenthood.

I had a new grad LPN orientee who couldn't/wouldn't enter male rooms first night on 11-7. She was foreign (Indian?) and single women were not to be on such intimate/private terms with males or something like that. How she made it through LPN school I don't know...but she wasn't on our unit the next night. Whatever made her think she could take a job on a med/surg unit? We were almost halfway into the shift before I caught on.

Other posters give very good opinions worth thinking about. Too much ambiguity on that grey slippery slope.

[RN/MSN1984]

where i work as he nightime supervisor at the hospital i have to be at that code when it happens. That becomes my priority.

[NicuGal, MSN, RN]

To the pedis nurse: we have claimed a few cases of futility and actually gone to court for a DNR, but the families were not really involved. Please tell me you would not go against a family wishes. We have also told them that we will only do X amount of med rounds and X never of things, but we have never just done what you described. That sounds like a huge liability! Hope your legal department is on board with you.

[jadelpn, LPN, EMT-B]

Yikes to the pedi nurse who chooses not to code. That is making a decision that parents have the right to make. If they make a choice based on whatever it is they base decisions on, then as a nurse, or a nursing team, are we not obligated to carry out those wishes?

Some parents are quantity over quality. And a child suffers, and it is heartbreaking. But it is a reality that no one knows--but can make an educated guess--whether someone is going to die.

The question that the OP had was different. If you choose not to participate in codes, that is a personal decision and one that has to go through the proper channels. What is troubling is that parents believe your team to "do whatever you can" to save their child, and it is decided not to do that. And I would not think that a decision that anyone would make but the parents.

What happens when child is allowed to die and no code is performed? What paper trail is left that details the recording of a code? If a dying child is on monitors, then one could assume that a nurse can't just sort of "go in and find the child not breathing, appears that child has not been breathing for a large amount of time"...Dependent lividity, whatever that may be. Further, if an MD "covers" by writing a last minute DNR, how does that cover anything? If an MD decides that a DNR is warranted, and it is against the wishes of the parents, then the parents need to make the choice of alternate care, not worry that the nurses are just not going to code the child.

This is an ethic's committee nightmare. And hopefully not the norm. Do I personally ever want to see a child live on machines their entire lives? Not necessarily, and neither do I as a nurse. However, I am acutely aware that this is not my decision to make as a nurse.