Code Blue: Pt was breathing, but Dr. pronounced dead

[Bugaloo]

I have a question: On our Med-Surg floor, we had a 80 year old patient that was A&Ox3. Her nurse had been talking to her, left the room for about 3 minutes, and when she came back, the patient had resp. of about 3 per minute, and she appeared to be dying.

Code Blue was called, we initiated CPR. We had done about 6 compressions, she had a faint carotid pulse, and was still "gasping". The Code Team arrived, and we told the physician that she still had a few respirations when we arrived (about 3 minutes before he did). She had a pacemaker, and it appeared that it was trying to "kick in" and do it's job.

He looked at her, felt for a radial pulse, and noted that it was faint. About 2 minutes later, he "called it", stating that her pupils were fixed and dilated, and that she had been dead "a while". We tried explaining to him that about 10 minutes prior to all this, she was absolutely fine. He did not listen and left the room.

My question is this? Did this physician pronounce this patient dead too quickly? We all felt very badly after this and felt that the code was not handled well at all. Did we do all we could for this patient, or did we let her die? Personally, because she still had a few respirations, I felt that we should continue, and so did the other nurses, but the doctor has the final word.

[bill4745, RN]

Incident report.

[Tweety, BSN, RN]

If she had a pulse and respirations, then yes, he called it too soon.

Perhaps he didn't want futile care, but doesn't sound like ACLS protocol to me.

[jmgrn65, RN]

If her pupils were blown than she was brain dead, maybe that is what he was thinking. If the code continued and you bought here back then she would probably be a vegetable (sorry lack of better word). then the doc would have to talk the family in a DNR and hospice consult.

[Diary/Dairy, RN]

Atropine can also cause fixed dialated pupils, did she get any???

[leslie :-D]

yes, it sounds like he called it too soon.

and i'd give him a hug followed by "good call".

leslie

[Ahhphoey]

I think he called it too soon as well. If there was still a pulse, than she was not deceased. As for the pupils, I've seen a patient with blown pupils eventually recover and walk out of the hospital with no deficits. Granted, she was only 22, but I don't trust a diagnosis based on pupil reaction unless it has been going on for at least several hours. As someone else mentioned, it can be caused by a medication and once the medication wears off, that affect will also. I've seen many futile codes that should not have been initiated in the first place, but thats not my call. Age alone is not a reason not to code someone especially if they are still living full active lives. If the patient and/or family decide to do everything possible, than I must respect that choice and do my job. Of course, if its a long term illness where we are more punishing the patient than saving them, I will advocate and make sure the family is well aware of what their choices will mean for the patient.

[suanna]

Called it too soon- very likely! Odds are the patient wasn't going to get out of the code alive anyway- something dropped her and a code doesn't fix everything. The fact that he based his "calling it" on pupils is the problem. Atropine, cataract surgery, dark room, some eye drops, antihistamines- you name it, can effect pupil status. I have never seen a doc call a code based on eye balls! Talk to your nurse manager and see what input they offer. If the doc was a resident perhaps his senior or supervising attending need to be made aware of your observations and review the code. If he was an attending you may have to involve you ethics committee or STAT proceedure committee. PLease keep in mind even with exceptional care most 80+y/o patients who code don't uncode. Your intention here is to correct a judgment error before it is used on a 25y/o who takes crack (and dilates his pupils) but unfortunately rips into VT while this doc is around.

[Bugaloo]

She did not receive atropine, or any other meds. We had barely started CPR when he called it. I kind of thought that you would need to check for pupil reaction to light, which also was not done.

I have seen little bitty frail folks with severe dementia worked on for longer than this. I am the first one to agree that there are times when a "slow code" is in order, but I don't think that this should have been one.

Thanks for all the replies.

[Jo Dirt]

This is one of the reasons I don't generally believe in coding very old and terminal people. It puts a lot of unneccesary strain on them.

[elthia]

Did she have a pulse after the 2 minutes of compressions?

Was she truly breathing or was it agonal respirations?

(3 breaths a minute, sounds like agonal to me, which could be a sign there was already cerebral ischemia)

What was the pt's admitting diagnosis, underlying history, and cardiac status and her prognosis to begin with?

Was her pacemaker in good condition?

And what was the rhythm on the monitor after compressions?

(If the rhythm showed asystole with pacemaker spikes without capturing a beat...he may have decided to let her go without traumatizing her body more.)

[DutchgirlRN, ASN, RN]

I think the doctor was using his better judgement in this case. You may think he called it too quickly but would proceeding with the code have changed the outcome? Likely not for the better. I think he was being compassionate. I would hope a doctor would do that for me when I'm 80 and have a cardiac arrest.