Dying Pts who are still full codes.

[NurseyPoo7]

We see them every once in awhile - at least on our floor. The older pts who have multiple things going against them, yet either them (if they are A&O) or their family still wants to be a full code. Their choice, no problem.

But since I haven't been in any code experience yet, I was wondering how it is handled when these pts finally code, or get to the point where us health professionals know the end is coming.

I'm asking, as there's a pt who has been on our floor about a month now - He's in his 70s, has a Hx of cancer, which was treated/organ was removed, now has cancer mets in at least 2 other part of the body - also is in CHF (last BNP I remember was nearly 3500), respiratory issues (doesn't help him he is about 350lb), bed ridden, incontinent, kidneys are failing, has had multiple paracentesis, swallowing issues so he's also on tube feedings.. Poor man is a mess. He's very nice and friendly, A&O, but as his choice he's still a full code. Someone brought hospice in, but I don't think he's ready for that yet. I think his family is finally starting to come to terms with exactly what's going on.

But with a patient like that, if he did start having issues not sustainable to life and we called a blue or rapid response, how exaclty would it be handled?

[Erin 321]

If it actually came to a code, at this point, as others have said, the code would be handled as per usual and the doctor would decide how long to proceed for.

The thing about these cases is you gotta think that if the patient really understood what it meant to be coded, and what his chances were, and quality of life, etc, etc, he would likely make a different choice. We all would, wouldn't we? Anyone who's seen it, and has some understanding of the likelihood of retaining your quality of life even IF (and it's such a big if) the code is successful, would likely choose to die with some peace and dignity.

Remaining a full code doesn't change the fact we're mortal.

For this reason, I would consider accessing other resources for this patient - a talk with the doctor, hospice, social work, pastoral care, whatever - just to ensure he's really making an informed decision. If he's fully aware of what a code means, including the stats on outcomes, and he still wants to proceed, then more power to him. I can't help but wonder if maybe he's scared, or perhaps feels he has some unfinished business, and could use some help working through that stuff, before it's too late.

[missjennmb]

In the UK the decision for resuscitation lies with the medic in charge, of course his wishes would be listened to and respected if at all possible but with his condition and co-morbidities resuscitation would more than likely not be attempted.

wow that kinda scares me to be honest...

it really makes me rethink the idea of universal healthcare...

if the patient wants to try everything humanly possible to prolong his life, shouldn't that be within his right? even if the nurse or doctor does not agree?

[missjennmb]

If he's fully aware of what a code means, including the stats on outcomes, and he still wants to proceed, then more power to him. I can't help but wonder if maybe he's scared, or perhaps feels he has some unfinished business, and could use some help working through that stuff, before it's too late.

Informed choice... I guess this is all that I'm truly advocating. The patient may not feel there is "some place better" after death, or may have last minute things they feel like they don't want to miss, or any of a number of things.

I'm not saying its what you would do, but if its what THEY chose, who's to argue? What if their personal belief is that a not so great quality of life is better than no life?

I guess I just don't feel like we should be in the position to chose who lives and dies, and at what point its not worth it for SOMEONE ELSE to give in and accept death. I can only hope that I have full use of my facilities at the end and am able to make that choice moment by moment until I pass, without it being made for me by those who feel they are doing the right thing for me.

[RN1989]

wow that kinda scares me to be honest...

it really makes me rethink the idea of universal healthcare...

if the patient wants to try everything humanly possible to prolong his life, shouldn't that be within his right? even if the nurse or doctor does not agree?

Doesn't scare me. I think it is ridiculous that we waste resources keeping people alive who are veggies, and continue to aggressively treat people who have NO chance of survival because they have money and/or insurance. Yet people without insurance and money are dying of everyday things like chickenpox and gastroenteritis simply because the resources to give reduced cost/free care are gone - because they have been squandered by someone else.

I think we could learn a few things from our UK counterparts.

[XB9S, BSN, MSN, EdD, RN, APN]

wow that kinda scares me to be honest...

it really makes me rethink the idea of universal healthcare...

if the patient wants to try everything humanly possible to prolong his life, shouldn't that be within his right? even if the nurse or doctor does not agree?

And everything possible would be done to prolong his life, but when it gets to the stage of having to jump on his chest when it is fultile I would question why?

I am not sure it is a concept of universal healthcare either, it comes down to the indivdual doctor.

I really do think it comes down to how you discuss this with the patient, many want to be for resuscitation because they are afraid that if not for resus then it means not for treatment. You can treat them with life saving measures to the point where they have a cardiac arrest, the resusciation by that stage is futile so why do it?

Doesn't scare me. I think it is ridiculous that we waste resources keeping people alive who are veggies, and continue to aggressively treat people who have NO chance of survival because they have money and/or insurance. Yet people without insurance and money are dying of everyday things like chickenpox and gastroenteritis simply because the resources to give reduced cost/free care are gone - because they have been squandered by someone else.

I think we could learn a few things from our UK counterparts.

I do like the fact that healthcare at the bedside in the UK is not driven by money, yes there are political issues but at the bedside money doesn't enter into it.

Just wanted to add that I also work with doctors who will not make that desicion, and I have resuscitated patients who have no chance of survival with multiple pathology and terminal disease. But as UK nurse, if I am the team leader of the resuscitation I am able to make the desicion to stop, obviously we decide as a team but that is something that I have and do take the initiative in.

[missjennmb]

but doesn't it come down to... if the patient requests it, it is attempted, and then if its not going to work then death is called? I am only a student, so I'm not as well versed in the procedures as an actively working nurse, so please forgive my questions.

Even though I am a nursing student, I have had some pretty negative experiences with doctors (one of which has come incredibly close to being a lawsuit and an issue with the board due to questionable judgement on the part of the obstetrician) and its hard for me to wrap my brain around the idea that a doctor would be able to override my choices, regardless of what they may be.

Perhaps its a product of my upbringing or because I am not in that situation, but I just don't like the idea of my choices being taken away. I had always thought that it was the patient that made the call as to when to give up and accept end of life care as opposed to attempting to find cures (given they are lucid enough to do so and in the case of the USA...that they have the financial backing to support that choice...but thats another debate)

[wonderbee, BSN, RN]

I've also heard of the slow code. I've never been part of a slow code. Can someone explain it?

[NurseyBaby'05, BSN, RN]

I can't tell you how many of my pt's are not too far from death's door and are still full codes. The docs often don't address code status with these pt's until the very last minute. These people could spend their last months living their lives with their families and comfortable rather than being tortured by us.

We had one recently that we finally bluntly told the docs to address her code status so that we didn't kill her with CPR or intubation. She had been there for months and her platelets only reached double digits twice in that whole time. Could you imagine if we had had to intubate her? Of course she was one of our falls when she vagaled down on her bedside commode. She lucked out with no head bleed. Still not sure how that one worked out, she must have one heck of a guardian angel.

Anyway, back to he original discussion, yes we have many actively dying patients who are full codes. I think a lot of them watch "doctor shows" and equate DNR with Do Not Treat. I also don't think the docs do a good job at helping them differentiate between the two. Possibly b/c a lot more money can be made on curative vs. palliative treatment. Just my .

[RN1989]

I don't want my choices taken away either, but people need to be accountable for their choices. These include the choice to be realistic with what healthcare can actually do.

People think that they can do anything to their bodies and we will magically fix them. The pharmaceutical industry has everyone programmed to think that if they just take a pill, all will be well.

It is very expensive to pop open a crash cart, and that is without using any of the supplies in it. It is ridiculous to spend the money on supplies and 10 people's time for a code on someone that is not going to survive.

As to the "slow" code. It is what is sounds like "slow" actions. And if you are ever caught using the term or accused of running a slow code, you will get into trouble with regulatory agencies and attorneys.

[XB9S, BSN, MSN, EdD, RN, APN]

but doesn't it come down to... if the patient requests it, it is attempted, and then if its not going to work then death is called? I am only a student, so I'm not as well versed in the procedures as an actively working nurse, so please forgive my questions.

Even though I am a nursing student, I have had some pretty negative experiences with doctors (one of which has come incredibly close to being a lawsuit and an issue with the board due to questionable judgement on the part of the obstetrician) and its hard for me to wrap my brain around the idea that a doctor would be able to override my choices, regardless of what they may be.

Perhaps its a product of my upbringing or because I am not in that situation, but I just don't like the idea of my choices being taken away. I had always thought that it was the patient that made the call as to when to give up and accept end of life care as opposed to attempting to find cures (given they are lucid enough to do so and in the case of the USA...that they have the financial backing to support that choice...but thats another debate)

Please don't apologise for being a student, your questions and opinions are as valid as anyone elses reguardless of your experience, and it may well be that you have a different opinion to mine, not everyone has the same point of view and it is so important to have these discussions because it explores all points of view.

I think I am more comfortable with what I describe because I have been nursing for such a long time and have seen so many undignified and gruesome deaths. Resuscitation is not a treatment for these patients it is really not going to work, they have incurable disease. It may be that this experience has made me a little cynical about the survivablity chances and I can acknowledge that this has an impact on what I feel about this subject.

Now we are not talking about young patients or those who have the possibility of survival here, we are talking about those patients who are end stage disease and there is nothing more medically that can be done to prevent the inevitable.

It is about informed choice, if they had an in-operable cancer, but demanded surgery the surgeon would explain that it is in-operable and this treatment was not an option because of the futility of it, in our scenario they have end stage terminal disease with multiple co-morbitities, there is nothing that can be done to make that end stage disease improve, they are deteriorating and it is going to end in thier death. You offer them the treatments and options that are going to make a difference to them at that time. That doesn't mean don't treat them, but personally I don't think that resuscitation is one of these treatments.

[heron, ASN, RN]

I don't want my choices taken away either, but people need to be accountable for their choices. These include the choice to be realistic with what healthcare can actually do.

People think that they can do anything to their bodies and we will magically fix them. The pharmaceutical industry has everyone programmed to think that if they just take a pill, all will be well.

It is very expensive to pop open a crash cart, and that is without using any of the supplies in it. It is ridiculous to spend the money on supplies and 10 people's time for a code on someone that is not going to survive.

As to the "slow" code. It is what is sounds like "slow" actions. And if you are ever caught using the term or accused of running a slow code, you will get into trouble with regulatory agencies and attorneys.

I agree that people need to be accountable for their choices ... I don't agree that we get to make the choice for them. I've come to see the decision to be DNR as a milestone in the process that pts and their families go through at the end of life. As with any other process, it takes the time that it takes.

I've had full code pts on my hospice inpt unit (it is illegal to require a pt to be DNR to be on hospice - which I support, BTW). I have stood by the bed of a dying (flaccid, gray with agonal breathing) pt and had to get verbal direction from the family to go to DNR. Not fun for me or the family.

I think it's not just the pharmaceutical companies that have hoodwinked people into thinking we can fix anything. Most folks' idea of a code is derived from TV: 30 seconds of shouting "Clear!", a couple of "whumps" from the defibrillator and, behold! -- Granny wakes up and smiles at her heroic rescuers.

Sometimes, it takes a "come to Jesus" meeting where we describe the implications of a full code in simple, common - not medical - language, detailing the brutal reality of a code and the likely outcomes.

On the other hand, there's a multitude of factors that can inhibit a DNR decision: fear of dying, fear of abandonment, guilt or simple denial, to name a few. As someone pointed out above, pts and families need time to work through this stuff. We can facilitate the process, but we don't get to co-opt it. It's simply not the professionals' decision to make unless a code is in progress and the MD calls it.

A "slow code", BTW, is an abomination in my view. My career goes back to the days before DNR was common. A slow code basically left it to the person finding the pt to decide how fast to call the code. Nope, not me ... not then and not now ... it's ACLS all the way until the family or the doc says stop.

[ayla2004, ASN, RN]

i been witness to one Multidisciplinary team decision to start a DNAR

the lady had both renal and heart failure had been seriously unwell for a week with frequent doctor input with no good effect. very calmly with her family present we went to no heroic measures DNAR and commenced on comfort care (LCP). Family had time to come to ease and be with mum, to me much better than the code i participated in ER (A&E).

DNAR are reviewed and stopped if a patient improves, are date limited and valid for only one admission.

A patient can request to be for resus in my hospital and i have seen this being an issue when a patient was admitted due to experiences with other hospitals.