Family Witnessing Code Activities

[BabyRN2Be]

With the new changes in allowing family members to witness code activities, would you want to watch your family member go through a code? I've heard this is done so that the family knows that the staff did all they could do, and to take the mystery out of codes. But would you want to watch a family member go through the pain of a code and all that it entails? What do you think?

[sirI, MSN, APRN, NP]

I don't mean now, but in say 20 yrs, if this becomes a standard, that people EXPECT to be present in codes. How will that affect DNRs when FP becomes a standard?

If we start teaching that FP is a wonderful 'closure' technique, might it also encourage the use of the technique, over other options?

~faith,

Timothy.

I believe that this will be less of an issue in 20 years.

[sirI, MSN, APRN, NP]

It has been my observation that most who oppose, oppose it on a personal level. And do not take into consideration the ramifications of a planned family member being present. And the understanding of a family member of the restrictions placed on him/her. It should be a family member's decision.

Grannynurse :balloons:

And, an excellent observation it is, grannynurse FNP! :balloons:

[P_RN, ADN, RN]

FP during the final time code or comfort I believe shows respect for the persons value. I don't want to use the buzz word closure, but that's what it was. We sat in a circle around the bed and told happy stories. One or the other was holding her hand. We sang to her hymns and rowdy ballads. We kept her turned and cool. Each nurse who came in was given a tiny insight into MIL life. This is FP to me as much as a messy code. We also made sure the doctor knew that WE knew the side effects of being in the arms of morpheus. I dopn't think it was any coincidence that her last nurse was named ANGEL. That was closure.

How many of you have been excluded from knowing the exigent

care of your loved one? How many of you are of an age where your peers are dying? So far I've counted 5 in my class. All these nurses were younger than I.

Do you have a living will? Health care power of atty? Do you have it AVAILABLE?

[Thunderwolf, MSN, RN]

and it's exactly why families cannot be surrogate decision makers for a patient in this situation. it is impossible to distinguish between your wishes as a family member and the potential wishes of the patient in this situation. and the gold standard for family members as surrogates isn't what they (the family) want, but their input into what the patient would want.

and the gold standard also isn't what nurses want the families to do, in order to create a standard.

without a patient's actual consent, fp is a violation of privacy.

~faith,

timothy.

couldn't have said it better, tim.

it comes down to privacy and the patient.

[Thunderwolf, MSN, RN]

FP during the final time code or comfort I believe shows respect for the persons value. I don't want to use the buzz word closure, but that's what it was. We sat in a circle around the bed and told happy stories. One or the other was holding her hand. We sang to her hymns and rowdy ballads. We kept her turned and cool. Each nurse who came in was given a tiny insight into MIL life. This is FP to me as much as a messy code. We also made sure the doctor knew that WE knew the side effects of being in the arms of morpheus. I dopn't think it was any coincidence that her last nurse was named ANGEL. That was closure.

I too have been in similar situations as a nurse. I worked a couple years in oncology as well. In the situation you describe, yes...FP during a no code, being with the loved one who is actively dying from a disease process is and can be a blessed event, due to the family coming together and supporting the dying member in word, in caress, in presence, and in care. However, the consent in this situation is given in consensus (both by patient and by family). Usually, there has been TIME for the patient and the family to discuss this together and the patient has shared his/her wish that family be present. This is totally different when a patient is full code, unexpected/in ER, without the consent of the patient. FP focuses on the family ...not the patient.

It raises issues in ER/emergency situations:

1. Consent of patient being coded...what is his/her wish?

2. If FP is established, what standard procedure and level of staff expertise will be in place to address the family? Will that level of expertise be available STAT 24/7?...if not the same level from days to nights, is the institution negligent in not providing the same level of care for the family? What level of "follow up" with the family will there be in place as well?...with intervention, in this case family, comes responsibility. What services would be provided if needed during follow up? What procedure does the institution have in place for a family member(s) who has been psychologically harmed from the practice?

3. Training of staff, particularily ER, who now would have to function under the scrutiny of family. What if a family member was a doctor or a lawyer or a nurse insisting to be present from beginning to end during a family member's ER code? How would the ER team function...better, the same, or worse under this level of scrutiny? What if the family member was taking notes or taped the code in progress? Is this statement true...all family members present during a code are there for the patient's best interest?

In no code, end of life scenarios (on the medical floors or in the units) where patient and family may have had some time to discuss who is to be present when death comes is one matter.

In "emergency room" full code with all the trips and alarms is another. No time to prepare. No time to discuss patient wishes. No soft gentle music playing in the back ground, only the hurried feet of the ER team and the sound of the doc and team's voices. Often hurried, chaotic at times, and risking sensory overload to a layperson...not peaceful at all. I think caution is not too much to ask. I think there needs to be MORE studies done in this area which meet tough research criteria that support this practice. In good research, it will lay it out...FP is effective with WHICH type of setting/environment, with Which type of scenario/context, with WHICH type of staff, and for WHICH type of family, and for how many family members....and good research will also show when it is NOT effective and when it can be detrimental. Any one who has done research and/or taken studies in research methodology can understand that any research can be flawed if it is not rigorously done and rightfully can challenge the conclusions...regardless if the outcomes seem positive. So, MORE research is needed in this area. There still is NOT enough data to support it to justify wide spread change.

Respectfully submitted,

Wolfy

:)

[renerian, BSN, RN]

I did see my mother code and I wish I had not seen it. It is permanented etched in my mind.

ren

[Tweety, BSN, RN]

I don't mean now, but in say 20 yrs, if this becomes a standard, that people EXPECT to be present in codes. How will that affect DNRs when FP becomes a standard?

If we start teaching that FP is a wonderful 'closure' technique, might it also encourage the use of the technique, over other options?

~faith,

Timothy.

I can't predict the future. But we shouldn't be teaching it as a wonderful closure technique. We should be giving the option and leaving the choice to them. Not promoting it one way or another.

[Tweety, BSN, RN]

Wolfy, you make valid points. If a facility is to institute FP, there should be training and staff availabe specifically for the family 24/7. In some facilities this might have to be a nurse, because this is what nurses do, help families cope with their loved one's conditions. Personally, I'd rather it be a chaplain, but that's not always practical.

The point being before FP is instituted a policy must be written and training provided.

You also brought up the point about patient privcacy. What about a patient who had a suddened illness deteriorated and the family extubates them and makes them a DNR. Do you ask them to leave during the extubation? Do you not allow them to be with them as they die? Does the patient have a right to privacy at this time.

The thought of my spouse or family watching me code, or even watching me take my last DNR breath bothers me tremendously and I'd rather have their last memories of me be happy one's not having my chest pounded on during a choatic code or perhaps gasping for air in a DNR death. (Why are codes choatic anyway, they should be smooth, calm, organized?). But I'm not going to make the decision or deprive them of the opportunity should they choose to be there. I'd understand if they couldn't be there, and I'd understand if they wanted to be there. I'm dying and won't notice or care anyway.

It's too much of a jump to say, during a code we have to respect the patients privacy, when in so many other cases we allow family participation without truly knowing the wishes of the patient when they can't speak for themselves and no will was left.

In my humble opinion of course. :)

[Spidey's mom, ADN, BSN, RN]

I've dominated this thread. My apologies to that.

Let me say that I'm am not discrediting the opposing point of view.

There are credible and substantial arguments on both sides of this coin. But that is exactly why this will always be a controversial topic.

Would I say that families can NEVER be in the room? No. But I think it also shouldn't be a 'standard'.

Have I seen families in the room during a code? Yes, I have. Do I approve? Not really, for several reasons, previously stated. But the families I've seen present were passionate about being there, which is a far cry from being 'invited'. I dont think it should be offered, but, by the same token, I've seen that it is often (not always, but often) not refused.

It's a difficult issue. I'm guess I'm glad that it's being discussed, but not if it's to the exclusion of the opposing point of view. This is one of the problems with nursing theory. Most of the articles I researched acknowledge that nursing is leading the way on this issue. It seems we go out of our way to adopt views without regard to our professional peers and then we wonder why we aren't treated as professional peers.

I won't say that I won't comment anymore, or that I'm dropping the topic - I think it can readily be inferred that I have an impassioned point of view. LOL. But. While I might respond to a comment here or there, I will take a step back and allow other opinions to emerge.

~faith,

Timothy.

I think this states my thoughts as well. Not a standard. But not something we always say no to.

Kat's comments about her son go right to my heart. I don't think I would want to see my children during a code . .. but I'm not sure you could keep me out. Not having been there - it is so very hard to really say exactly what you would do.

((((Kat))))))

steph

[Tweety, BSN, RN]

I think this states my thoughts as well. Not a standard. But not something we always say no to.

Kat's comments about her son go right to my heart. I don't think I would want to see my children during a code . .. but I'm not sure you could keep me out. Not having been there - it is so very hard to really say exactly what you would do.

((((Kat))))))

steph

You say you're not sure they could keep you away from your child. Wouldn't it be nice if you had the choice so the "scene" of you demanding to be with your child could be avoided?

The original topic was would we like to witness a loved one's code. However, (off topic) when deciding a policy for your unit/hospital our personal choices should not necessarily come into play. It's not fair to put our personal choices on everyone. Offer the choice and leave it at that, and support them one way or another. It's perfectly understandable and reasonable to not want to witness a code, and the movement towards FP doesn't demand witnessing a code, just offering the choice.

Whether or not I want to see my loved one coded shouldn't come into consideration when offering it to others.

In regards to Kat's comments, the code team should be in charge of the code and the family doesn't run the code. The family is with a support person, out of the way. Following ACLS protocol, not family wishes is when the code should end. Letting family in, shouldn't change a thing that you do during a code.

Again, just a humble opinion.

[grinnurse, RN]

About 10 yrs ago I watched them do a code on my sister, (inadvertently) and can honestly say that I would never want to witness that again on a family member. I had nightmares from that experience and some of the last images that I had of my sister for a long, long time was of that. No thanks for me.

[traumaRUs, MSN, APRN]

In the end, the only thought to take from this very enlightening discussion is that there should be a choice for the families. I always tell the families there is no right way or wrong way, whatever you want to do is fine - we will support you. BTW - our facility does have a written policy and it is enforced 24/7. However, I certainly view the concerns of the nurses from smaller, rural hospitals as very legitimate. Staffing must always be considered when writing policies.