Do you approach patients or families about code status?

[RNinICU]

In your hospital, who approaches patients and/or families about the patient's code status? If a patient takes a turn for the worse, and some one needs to find out how aggressive the treatment should be, do nurses or doctors talk to the families? Or if a patient has been on support for a long time and is only being kept going by the machines, who talks to the family about discontinuing treatment? As an ICU nurse, I have often updated families about a patient's status, and discussed the option of making a patient a DNR or discontinuing an ineffective treatment. Only one of our docs has a problem with the nurses talking to families about code status. He is an older doc who seems to think that the nursing staff is usurping his authority. My SIL works in another state, and she tells me that nurses at her hospital never discuss code status, only the docs do this.

I am not talking about giving complicated details of treatments and procedures, I am just talking about finding out from families what their wishes are regarding code status.

[BadBird, BSN, RN]

I keep the families updated on the condition, I ask if they are aware of the code status and if they want to make any changes, if the family wants a no code status I call the resident on call to come talk to the family and fill out the correct paperwork. You have go have a sense of how the family feels about such things, some families are so ridiclious that ethic committee needs consulted, with them I let the doctors deal with them while the poor patient hangs on by a thread. Other families want direct information and feel that the doctors are blowing them off, they appreciate an honest approach.

[Nurse Ratched, RN]

Since the nurse spends more time with the patients and families, it seem like we have a better rapport built up to discuss a sensitive subject like this. The main doc I work with is not as comfortable doing this and seems almost relieved when the nurses bring it up with the patients and their loved ones.

[misti_z]

I have discussed code status and condition with families, and have not come across a doc is is opposed to nurses doing this. If it is a pt who would have zero quaility of life after a code, that is if they made it through the code, I will ask family if they know the pt's wishes. I discuss options with them and what is involved in different types of codes (e.g. full code vs chem code). We also have a great case manager who is good about discussing wishes with families and who usually gets the ball rolling on a pt who is to be made a no code.

[Tiiki]

I work in the ER, and I've also worked the floor. It has always been the Dr's responsibility to deal with code status. They are the ones who appoach the family and patient. We can update the family on the pt's condition, but it is beyond our relm to bring forward DNR orders. We also call the family if the condition of the pt changes, but if the pt dies, again it's the MD who deals with it.

Jo-Anne

[jevans]

I agree with Nurse Ratched, even though I work with stroke patients we have more time with patient and family. We always consult the family.

Have just come from a harrowing shift where a patient had developed a major pneumonia, renal failure and bless his soul and given up! We checked with his family yesterday and the poor guy died today.

The family response was that we did everything to support him and them

j

checked for spelling

[ceecel.dee, MSN, RN]

Often times, the nurses ask the doctor if he knows the code status. If he says "that did not come up" like he's waiting for the patient to let him know just as we are starting compressions, with sign language or something, than most of us have gone ahead with this discussion ourselves. Some of our docs are more comfortable with this and might even say, "Oh yeah, it'd be a good idea to have that info".

So, I guess none on them feel particularly usurped if we go ahead.

I, personally, feel that it is the doc's responsibility to know this ahead of time.....how does one write orders on another person who has rights of self-determination. It shouldn't be left until the bitter end, when it is really scary talk.

[Sleepyeyes]

That's the first question on our admit form; we re-address it prn with major status changes.

[adrienurse, LPN]

In my last jobs, social work did a lot to help with this. This is a delicate matter, after all. Where I work now, it is the sole responsibility of the nurse. Sometimes it is done well, sometimes not, and the resto of us have to clean up the mess when a crisis arrises.

[bandaidexpert, BSN, RN]

Our SSD usually is responsible for this task, however, I tend to call the family for a meeting with the team. Oftentimes we are put in the position to inform families of the need for LTC for the rest of their born days, this is the time we discuss AD's. Our Medical Director requests all resident's with progressive dementia dx have DNR's.

[fedupnurse]

We do it all the time in our unit. We have a bunch of docs who hate it when we ask. If they make themselves a DNR then maybe they won't want that heart cath and then there goes the boat payment. We also have quite a few docs who give conflicting info to the families. In one breath they say to us "I don't know why they won't make him a DNR." and then you hear him say to the family "Let's give it some more time and see how he does." HELLO!!!! Can you say mixed message??? We lay it on the line for the families we feel are ready to hear the truth. Not that we don't advocate for the patients with the unrealistic families, but if we have people we know are on the brink but just need the "permission" if you will, to make the hardest decision of their life, we help them in whatever way we can.

We are not supposed to talk to families about organ donation. We are supposed to call the supervisor who calls the sharing network. I break this rule routinely. It is just so stupid.

[leesonlpn]

Of course every situation is different. Some doctors refuse to make their patient a no code - feeling it would be a personal failure no doubt, unless a family member requests it. Here in my hospital a lot of doctors absolutely hate addressing the code status issue. They are there for just minutes usually, while we have the 98% the rest of the time. If a patient is going sour, depending on his age, secondary diagnosis etc, I will bring it up with the family. I encourage them to get together to discuss the situation, and whatever they decide, to let thier doctor know, or I will write it on the doctors board to be addressed. I think there should be a trainex film entitled "CPR. LIVE!" Then these family members who want everything done for their 96 year old father who has a history of everything and is dying of everything, can see dad's ribs cracking, and being zapped and the beauty of being intubated. By all means, save the ones you can, but be realistic. I believe in death with dignity. Some family members have even chosen to ignore their parent's living will for heavens sakes. As for discussing it with the patient, I can usually take clues from a conversation. Sometimes the patient will say, I've had a good life, or I'm tired of being sick, I hope I sleep and never wake up. Those are usually good clues, to perhaps expand on.