Code status and end of life should be nursing decisions.

[Woodenpug]

O.K. another cold code. I don't want to make a long post about something we have all experienced.

Nursing is the human response to health and health conditions. Would it not be more appropriate if we were equally important to determining the patient's code status as is the MD? If for no other reason than that nursing is collaborative and we would be concerned about the patient.

Under ideal circumstances survival to discharge for a code is roughly 1 in 100. Modified codes are less than ideal circumstances.

The patient is informed that to be intubated means a life on the respirator and consequently decides, with the MD, that a modified code is appropriate. How often does the patient know that the possibility for survival to discharge, after a code, without a protected airway is zero? The MD is preforming outside his expertise in assuming that the patient's response to the health condition would be to prefer no intubation without the possibility of d/c. The MD lacks the tools necessary to make an appropriate nursing diagnosis.

[angel_nurse_83]

As a nurse in Ontario we are responsible upon admission to go through the End of life Decision Status: dnr, restricted resucitation, or full code... It is not up to MD or US to deside what the pt. should be... It is their choice.. and of course if they are not able then SDM.

I have had many instances in which someone is DNR and at the last minute they state they want to be full code... then away with the procedure we start...

Hmm.. NOt sure how things operate in USA.

[loriangel14, RN]

I think that things are different up here. I know that the code status is decided by pt or SDM like you said. It is part of admission information most places and the doc cannot change it.

[Silverdragon102, BSN]

Just goes to show how things are decided around the world. Here in the UK the doctor/consultant in charge of care in the hospital can make the decision without the family consultation although this is more than often taken into account and the nurses get more involved as they tend to deal more with the relatives than the doctors and I have at times approached patient/family about this.

[Woodenpug, BSN]

"Remember patient rights? I think it's called a health care directive. If none than the family needs to make an obviously painful decision. They are family, and IMO we are the caregivers."

The right involves informed consent. A consent to a modified code is a consent to be assured that if you code and you survive, you will spend the rest of your life in the hospital. If you do not survive a modified code it is consent that your last moments on earth will be spent enduring violent invasive medical procedures. I believe that decisions about code status are rightfully in the domain of nursing and not medicine. Of course, it is the patient who should decide. That decision should be made understanding the full consequences of that decision. This would seem to be the human response to health and health conditions. The title I used was just that, a title. I can not believe that an informed person would agree to a modified code except in very rare circumstances. Most informed people would choose full code or no code, if they were fully informed. Rare circumstances could be awaiting the birth of a grand child or another special event.

[sharona97, BSN, RN]

"Remember patient rights? I think it's called a health care directive. If none than the family needs to make an obviously painful decision. They are family, and IMO we are the caregivers."

The right involves informed consent. A consent to a modified code is a consent to be assured that if you code and you survive, you will spend the rest of your life in the hospital. If you do not survive a modified code it is consent that your last moments on earth will be spent enduring violent invasive medical procedures. I believe that decisions about code status are rightfully in the domain of nursing and not medicine. Of course, it is the patient who should decide. That decision should be made understanding the full consequences of that decision. This would seem to be the human response to health and health conditions. The title I used was just that, a title. I can not believe that an informed person would agree to a modified code except in very rare circumstances. Most informed people would choose full code or no code, if they were fully informed. Rare circumstances could be awaiting the birth of a grand child or another special event.

I disagree and here is why. I have a health care directive with a POA and both notarized and legal to my wishes. For instance, no tube feeding, if an event happens that puts saving my life back into the state it was in before the accident, or MI, I've made it clear that I would accept CPR. If in the Dr.'s decision that I may sustain hypoxic brain damage, let me die in peace. I laid out a very detailed DIRECTIVE for both the provider(s) and family, albeit a difficult wish to follow, it is a legal document.

It enlightens the caregivers my rights as a patient, it has a title, so does the phone book. The titled document concerning my healthcare, procedures in an event, etc. is a legal document. And there are many copies to the lay person as well as to family and next of Kin, who has the original copy.

I do understand what your point is and how it connects into caregiving, but unfortunetly the patient rights that are legalized and documented are done in such a manner for a reason and IMO should be followed. My POA has contractually agreed to see that these wishes are followed, even if in and of itself causes death.

[Woodenpug, BSN]

I disagree and here is why. I have a health care directive with a POA and both notarized and legal to my wishes. For instance, no tube feeding, if an event happens that puts saving my life back into the state it was in before the accident, or MI, I've made it clear that I would accept CPR. If in the Dr.'s decision that I may sustain hypoxic brain damage, let me die in peace. I laid out a very detailed DIRECTIVE for both the provider(s) and family, albeit a difficult wish to follow, it is a legal document.

It enlightens the caregivers my rights as a patient, it has a title, so does the phone book. The titled document concerning my healthcare, procedures in an event, etc. is a legal document. And there are many copies to the lay person as well as to family and next of Kin, who has the original copy.

I do understand what your point is and how it connects into caregiving, but unfortunetly the patient rights that are legalized and documented are done in such a manner for a reason and IMO should be followed. My POA has contractually agreed to see that these wishes are followed, even if in and of itself causes death.

What I'm trying to say is that more patients would have the type of arrangement that you have if end of life and code status was considered a nursing issue rather than a medical issue. I applaud your choices and they were obviously made with a full understanding of the situation.

You describe something different from a modified code. A modified code is withholding

one of the essential elements of resuscitation. No intubation, no cpr, no cardiac drugs or no defib/cardiovert.

Once again thank you for addressing my post in a thoughtful manner.

[VegRN]

Actually, physicians can make a patient no code, if they judge that any further intervention would be medically futile. Physicians are under no obligation to offer care that they do not believe would provide benefit to the patient. This can include intubation, resuscitation, etc, and it does not require the consent of the family or patient.

Obviously this is rarely done, but it does come up from time to time.

I've seen this happen a couple of times and in both cases I strongly agreed that it was in the best interest of the pt. In one case the pt had terminal cancer and in another case the pt had multiple organ failure. Both insisted that they be full code but the Md made them a no code because there was absolutely no chance it would benefit them. Both of the pts died within 1 week of being transferred to other facilities which was expected in both cases.

[platon20]

Doctors would be happy to give up code decisions to nursing. They dont get paid for it, and its a very time intensive, pain the ass process to go thru.

Now, do you agree to accept FULL LEGAL LIABILITY for your code decisions? Or are you going to go run and hide behind the hospital shield?

If nurses really want the authority to decide code status, then they'd better be willing to take full responsibility for it too.

If nurses run and hide behind the hospital every time a lawsuit comes up over code status, what will happen is that the hospital will come up with new policies mandating that only doctors can decide code status so that the legal liability is pushed off the hospital and onto the doctor's private malpractice coverage.

[smk1, LPN]

Doctors would be happy to give up code decisions to nursing. They dont get paid for it, and its a very time intensive, pain the ass process to go thru.

Now, do you agree to accept FULL LEGAL LIABILITY for your code decisions? Or are you going to go run and hide behind the hospital shield?

If nurses really want the authority to decide code status, then they'd better be willing to take full responsibility for it too.

If nurses run and hide behind the hospital every time a lawsuit comes up over code status, what will happen is that the hospital will come up with new policies mandating that only doctors can decide code status so that the legal liability is pushed off the hospital and onto the doctor's private malpractice coverage.

The tone of this post seems a bit unnecessary...

[Woodenpug, BSN]

Yes, I always accept full legal and ethical (kinda redundant since our ethics are legislated) responsibility for my acts of omission as well as commission. I believe this is true for most nurses.

I am less frustrated now, because at my facility, they have added the phrase "continue with aggressive therapy" to DNR orders. That small addition has decreased the number of modified codes to almost nil.

[nurseby07]

I've heard of nurse's having the authority to determine code status. I think it was call a slow code