Can a nurse refuse to participate in a code?

Tait, MSN, RN · Jun 1, 2013

For me I would try to advocate for the patient before the situation came to a code. If I had done my best to change a status for the patient, I would then participate in the code. That is my responsibility to the patient.

Esme12, ASN, BSN, RN · Jun 1, 2013

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.

I understand what Kell is saying......and there are times I long for the days when families weren't placed in the position of making this heart breaking decision of letting their child go.

Children die. Children become brain dead. Brain death is legally dead. Physicians are not obligated to treat the dead. Allowing the parents to "come to a decision" to allow them "control" and "participation" in their child's care isn't always the best decision....although it is what should be done if at all possible.

It is more difficult when the media talks about people being declared brain dead somehow resurrecting themselves back to life. Either the media has it wrong or someone didn't understand OR do a real brain death protocol. The first child I removed from life support ....I will never forget her......she was brain dead (from massive head trauma after being hit by a car) for a few days and the parents wanted everything done if she "coded" because they knew of a case where someone went on to live a normal life.

I went to see the Cerebral blood flow study myself for if I was going to remove this child from life support I had to know for sure......the blood flow to the head stopped at her jaw. The line of demarcation was very clear.......It was one of the most profound things I had ever seen. I knew I could removed this child from the machines for she was already in heaven.

But the parents wanted everything done. It was agreed to let the parents to have time to let her go...to come to grips. But that is very difficult when they "see" nothing has changed....same tubes, a heart rate on the monitor, the chest rising and falling .....just like all the days when we were fighting for her life...."she cannot possibly be dead".

It was decided if this angel coded before her parents decided..... we would not code her.....to ask the parents to leave as we always did, call the code, and quietly close the door.......and I was perfectly comfortable with that.

On the other hand.......If it was decided to code her and I had to....I would have had to step aside and let someone else care for her, after being her primary for several days, because she was already gone....I would not be able to torture her any more that she had already been tortured with all of over miracle cures and IV lines, central monitoring, ICP, brain drains, skeletal traction, drugs and blood transfusions.

Am I comfortable withholding resuscitation...it depends on the case but yes I am. Would I refuse to code someone even if it meant my job? In this case that would be yes. ...for if medicine didn't have the gonads to make the right decision someone else needed to care for this patient.

Is it always clear as mud? No. The parents decided after many heart rendering conversations to remove her from life support and let her go. One of the most difficult things I had ever done.

I remember a family of an adult that insisted everything be done on their mother who was brain dead after a massive brain hemorrhage....again negative CBF...that even when the MD's were very clear that they were not going to do anything...this family just didn't or couldn't get it....their mother was gone. After a couple of days and massive inotropes it was clear this lady was going to asystole any second....this family punched the MD and the police had to be called becasue the MD told them their mother was brain dead and is legally dead and the patient was going to be removed from life support...the family wanted to fist fight. This patient "coded".....although she was not coded. I heard the family tried to sue and it went no where as there was no case.

So there are cases where I would say no or participate in a slow code....and hope for the best.

Jory, MSN, APRN, CNM · Jun 1, 2013

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...

You can refuse to hang blood because of religious reasons because rarely, is it an instant, life or death issue and another nurse can do it.

You can refuse to participate in an abortion, for one, because they are usually not done in the hospital (never encountered one...ever), because again, that is an elective procedure that is never an emergency, therefore, someone else can do it.

However, if you want to pick and choose who you code and don't code, my suggestion is to get into another profession or work in a clinic where you are very unlikely to code a patient.

THAT PATIENT'S LIFE IS THEIR DECISION...it is not yours. You don't get to make a life or death decision for SOMEONE ELSE based on YOUR beliefs and YOUR feelings.

That is because it would be endless of where you draw the line. It is not even a slippery slope...if a nurse wants to pick and choose who they code/don't code...then I'll show you a person that doesn't need to be working as a nurse in a hospital or any acute/emergency setting.

Blows my mind that you would think it is remotely reasonable. Codes are life and death emergencies with seconds that matter, so you don't have time to put your hand on your hip and say, "Uh, can somebody else get this?"

They would have every reason to fire you if you did...and should.

MomRN0913 · Jun 1, 2013

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.

I don't know if hospice is inpatient or out patient, but it is in our consent forms for home hospice that we do not perform CPR. So if their was an 11 th hour decision change and the nurse is in that home we are not obligated to do CPR.

Guests · Jun 1, 2013

The first child I removed from life support ....I will never forget her......she was brain dead...
I went to see the Cerebral blood flow study myself for if I was going to remove this child from life support I had to know for sure......the blood flow to the head stopped at her jaw. The line of demarcation was very clear.......It was one of the most profound things I had ever seen. I knew I could removed this child from the machines for she was already in heaven.
...
It was decided if this angel coded before her parents decided..... we would not code her.....to ask the parents to leave as we always did, call the code, and quietly close the door.......and I was perfectly comfortable with that.
On the other hand.......If it was decided to code her and I had to....I would have had to step aside and let someone else care for her, after being her primary for several days, because she was already gone....I would not be able to torture her any more that she had already been tortured...
Am I comfortable withholding resuscitation...

A couple of thoughts:

1) If the patient is already brain dead... that is, dead... are we torturing them anymore? Desecrating/mutilating a corpse, perhaps, but torturing a person?

2) Terminology is a huge part of the problem and reveals our collective bias and, for some, misunderstanding...

For example, we call it "life support" even though the brain-dead patient isn't 'alive' beyond cellular function. ECMO, mechanical ventilation, tube feeding are all descriptive... "life support" sometimes is not.

Even the term 'resuscitation' implies something more than it often delivers... as opposed to 'external compressions' or 'circulatory support.'

This is a very tough issue for everybody, particularly those working with the very old and the very young... and the heme-onc folks.

KelRN215, BSN, RN · Jun 1, 2013

Brain death is determinant of death in all fifty states. Medical teams are under no obligation to have family consent before withdrawing artificial support in a brain dead patient, whether the family wants "everything done" or not. In the case I was referencing, the child had a fatal brain tumor... a brain tumor that no one survives and she had been actively dying for quite some time. She ended up trach'd, vented and G-tubed which I've rarely seen in patients with this type of tumor. (The Ethics Team was consulted prior to the trach and the ORL team did NOT want to do it... The Ethics Team agreed to it only because they knew that it would do nothing to prolong her life.) This family had used all of their resources to bring her to our hospital, believing that as a top ranked pediatric oncology hospital we'd be able to fix her. The MDs were honest with the parents from the beginning- we have nothing more to offer you save for phase I clinical trials. This tumor has a median survival of 9 months. She remained a full code the entire length of her illness. Once she was pronounced brain dead, the family was told that support was being withdrawn. And everyone was on board with that decision. CPR does nothing to reverse brainstem herniation.

I have never had to not code a patient who was a full code but I HAVE seen situations where the parents- waiting for some miracle that wouldn't happen- refused to make the child a DNR even though it was clear that the end was near. And we- the medical team (usually oncology), the nursing team, the palliative care team, the ethics team, the legal team- had conversations where we discussed "what would we do if this patient coded before the DNR was signed?" And it was usually the doctors who said "we won't do XYZ." The cause of death in the majority of these patients was brainstem herniation- therefore these patients are brain dead. Fortunately in all of these cases that I've seen, the family agreed to the DNR- sometimes "just in time". Often times they made the decision because in order to give the child the dose of pain medications they required to keep them comfortable, per hospital policy they HAD to be a DNR.

As far as the feeding tube thing goes... I recall a case where a child progressed to being end of life very quickly. Only a week or two earlier, he had been started on a clinical trial of oral chemotherapy and at that time he was still awake enough to swallow it. He quickly progressed to the point of being obtunded and unable to swallow. I was caring for him on the day where his mother asked if we would put in an NG tube so that he could get this medication. The MD told her no.

Esme12, ASN, BSN, RN · Jun 1, 2013

A couple of thoughts:
1) If the patient is already brain dead... that is, dead... are we torturing them anymore? Desecrating/mutilating a corpse, perhaps, but torturing a person?
2) Terminology is a huge part of the problem and reveals our collective bias and, for some, misunderstanding...
For example, we call it "life support" even though the brain-dead patient isn't 'alive' beyond cellular function. ECMO, mechanical ventilation, tube feeding are all descriptive... "life support" sometimes is not.
Even the term 'resuscitation' implies something more than it often delivers... as opposed to 'external compressions' or 'circulatory support.'
This is a very tough issue for everybody, particularly those working with the very old and the very young... and the heme-onc folks.

Are we torturing them...IMHO yes. But that is an emotional/spiritual response not a logical scientific response...but that 's me.

In both cases the MD's were actually pretty honest and did a good job. The child's family finally had the child removed from life support they were ready to say goodbye....the other family they were well......different. That ranks on one of my top 10 bizarre moments as they accused us of murder and called the police....I need to write a book.

But I agree terminology is a huge factor and some MD's are just not good at it....using terms like to help someone breathe...many do not understand what "code means" and are shocked when they learn what goes on.

PMFB-RN, RN · Jun 1, 2013

Yes! I have done so a number of times. I didn't get in any trouble however, YMMV. Like MunoRN they were cases where it was firmly established that the patient wanted to be DNR and when they could no longer make their wishes known their family changed their code status. I will NOT provide care when my patient has made an informed decision that they don't want regardless of what the physician or family say or demand. The first time I refused to code a patient I fully expected to lose my job and possibly face the BON. However nothing was ever said to me about it except "thank you" in private. Since that time I have refused to code other patients, including one case where a surgeon was irate and demanding I code them (he wasn't there, he was on the phone). I am my patient's advocate. I hope that it doesn't mean I will lose my job or license, but I have to look at myself in the mirror and live with my decisions. It would be hard for me to live with myself if deliberately I inflicted pain and suffering (harmed them) on my patient who had refused it

I am the code administrator for my hospital and the full time rapid response nurse so when I refuse to code it means there will be no code.

FWIW I do know of a case where a patient was coded against their will and criminal charges of battery were brought against several staff, including a nurse. He was even arrested. Charges were later dropped when the patient died but that nurse (who was following a physician's orders) had to live with that hanging over his head for several months.

PS Wanted to add: Many times I have participated in code that I felt were wrong but the patient had made an informed decision that they wanted to be full code despite the futility of it. I feel dirty and evil when that happens but I don't feel like I can go against the patient's decision. It's not my place to do so.

PMFB-RN, RN · Jun 1, 2013

Are we torturing them...IMHO yes. But that is an emotional/spiritual response not a logical scientific response...but that 's me.

*** And me.

I need to write a book.

*** I will buy one of the first copies! However I know from the times I have told hospital stories to non hospital / EMS types that Americans are not ready to hear your stories.

But I agree terminology is a huge factor and some MD's are just not good at it....using terms like to help someone breathe...many do not understand what "code means" and are shocked when they learn what goes on.

*** If it's a "bad" code I try to get the family as close to the bedside as possible in the hopes they will yell "ENOUGH!". In a "good" code I try to get them far away so I can concentrate on my work.

My personal advanced directive is highly detailed and currently runs to 14+ pages. I have it on a Word template somebody gave me. Not unusual that after a tough shift I will sit down and add to it, print, sign and shred the old one. My best insurance against a slow lingering death in the ICU is my wife. She is my POA for health care and is the beneficiary of a TON of life insurance. She won't hesitate to pull the plug on me (just kidding).

Most all the advanced directives I see are useless. They use useless terms like "persistent vegetative state". As WE all know a heck of a lot of terrible things can happen to you, like multiple organ failure, that will earn you a long, slow and painful lingering death in ICU without any part of your advanced directive kicking in.

My experience is that, despite the face that I am an atheist, a great chaplain is the best asset to have available in these situations.

Guests · Jun 1, 2013

Are we torturing them...IMHO yes. But that is an emotional/spiritual response not a logical scientific response...but that 's me.

For completeness, I don't disagree with you... I'm a reasonably strong dude and have pulverized my share of fragile, old ribs... and generally feel like crap about it.

some MD's are just not good at it...

Ain't that the truth. I hear a lot of docs either beat around the bush with the patient right after having stated the obvious to me or else going on in 'doc-speak.'

One of the things that I like about being in an academic medical center is the opportunity to help teach the med students and baby docs to speak like people rather than like docs. I've several times followed them out of the patient rooms and said, "They have no idea what you just said to them."

NicuGal, MSN, RN · Jun 1, 2013

But times have changes, parents do not have to leave when their child is coding, it is their right to stay there. Sometimes this is better because we have has parents see this and then decide enough is enough. It is just a sad and difficult time all around.

kalevra, BSN, RN · Jun 1, 2013

Of course you can. Its actually very simple.

When the code begins, just walk away in the opposite direction and mumble to yourself about picking up blood/meds/admit/discharge/ break.

lol