Code Blue in the ICU

I don't blame you a bit, saernurse.

What bugs me is that patients will have DNRs and Living Wills stating their wishes, and then some family member in complete denial will come in and be allowed to totally override that person's decision, allowing G-tubes, vents, all the stuff that the patient did not ever want to have.

It's just not right!

Yes, we see this so much! I know that it is hard for some family members to let a loved one go.... but the patient is going through so much pain and suffering! It is really hard to see your patient hang on for days...... and you as a nurse know that the patient is not going to make it..

I , too, see this more often than is necessary. The problem is so multifaceted; patient, families, doctors, religious beliefs, etc. (not to mention, guilt!)

All we can do is speak the truth and constantly update the family with observations about their loved one. Sometimes it takes families a day or two or three...to come to terms with the truth to feel comfortable enough to make the DNR decision. And somtimes that is too late; we've already cracked more ribs with compressions, burned more skin with shocks, etc.

I've talked to the docs on several occasions and told them I would not do compressions if this particular patient coded, (although I probably would have in the heat of the moment), and this was enough to get the docs to talk to the family and encourage the DNR order. On separate occasions the patients died within hours of receiving the order. During those precious few hours I was able to spend my time explaining the dying process to the families and encourage them to talk to, hold, cry,etc with their loved one. We also offer to make hand prints and cut a lock of hair should the family want these. We then give them a "memory box" in which to store the handprint and hair as well as cards, etc.

I try to have the families bring their priest, pastor, minister, rabbi, etc., to the hospital to help them with the decision making process. Sometimes they need to hear that it's ok to let their loved one go.

Having said all this......it's still never easy and it still happens too often.

Melissa

I'm sorry. I do think this is the worst part of nursing.

I agree with everyone and I think some of these DNRs are also so broad and are not explained to the family in depth. I mean we have patients that the family does not want them intubated but please ponder on their chest and shock them over and over again but they still will not live. Or they do not want CPR, defibrillation, intubation but please push meds. I know that the family does not understand without CPR those meds will not do very much. I think sometimes it is for a comfort measure for the family to say that at least they did something to save their family member but when it "enough-enough?" I also find this very frustrating as a nurse and I do not have any issues with discussing this with families because I feel it is their right to know what we are going to do to their loved one.

I don't know what your personal experiences are, but would ask you to be careful not to judge too harshly unless you have been in the family's shoes.

I have.

When my mother had her first cardiac arrest, I witnessed, did CPR, she recovered.

Years later when she had the second, I was not there. The ambulance crew coded her for something like 20-30 minutes and got a heartbeat back. She was intubated, etc. Initially, we stated that we wanted aggressive treatment, until we could see if she could recover. Vent, external pacemaker, drugs, etc. 12 hours out from the event she was going tachy and requiring multiple conversions. At this point the one doc looked at my family and asked "how long are we gonna keep doing this?"

Well, let me tell you, he was lucky he didn't get his block knocked off.

Keep in mind that 14 hours earlier this woman was Christmas shopping for her grandchildren!!!

After observing her, talking amongst ourselves and talking with the neuro doc and internal med doc, we decided after about 2-3 days to make her a DNR when it was apparent that she would not recover.

She died 10 days after the initial event, after a gradual reduction in interventions. (removal of vent, pacer, meds, etc)

I believe that my family and I handled the situation appropriately and that that doctor was completely out of line suggesting that we stop trying less than 24 hours out.

I don't know what your personal experiences are, but would ask you to be careful not to judge too harshly unless you have been in the family's shoes.

I have.

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Kitty, thank you for your post. I guess it would have been wise of me to let ya'll know that these patients had been in our ICU for more than 3 weeks and that it was and is always hard to make a decision in that time. I always am as non-judgemental as I can be however it is hard to see someone suffer. I am sorry that you had to go through that and thank you for sharing that with us.

I can understand the frustration being asked to make a decision just 24 hours after the event. It is hard to be nonjudgemental being the field we work in on a daily basis and we see how some of these patients do suffer. I have been on the other side of the fence also and it is a very hard decision to make. You really need factor the of what would the patient want.. would they want to be on life support and have their chest beat on from CPR repeatedly and all these medications being adminstered just to keep them alive? That is why I firmly believe in a living will and advance directives for patients. I also believe talking to family members before anything happens about my wishes. I want them to know that I do not want my end of life sustained through artifical means. I want to be made comfortable and let go peacefully. I think communication is the key factor.

I can understand the frustration being asked to make a decision just 24 hours after the event. It is hard to be nonjudgemental being the field we work in on a daily basis and we see how some of these patients do suffer. I have been on the other side of the fence also and it is a very hard decision to make. You really need factor the of what would the patient want.. would they want to be on life support and have their chest beat on from CPR repeatedly and all these medications being adminstered just to keep them alive? That is why I firmly believe in a living will and advance directives for patients. I also believe talking to family members before anything happens about my wishes. I want them to know that I do not want my end of life sustained through artifical means. I want to be made comfortable and let go peacefully. I think communication is the key factor.

EXCELLENT post.

It's extremely difficult for me to watch a patient needlessly suffer for days on end while the family agonizes over a decision. Clear communication and documentation of wishes could prevent a lot of that.