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Full Code required for surgery?

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KDPatty KDPatty (New) New

This is a new one for me, so I'm wondering how prevalent this is.

I work in an LTACC, that is based within a host hospital. In order for our patients to have any surgical procedure, they have to be FC.

Lots of times we send a pt down for surgery, that requires intubation, they fail to wean, and we get them back a few days later, still intubated or trached and pegged. Often said patient was DNR or DNI prior to surgery, and they get re admitted to us as FC.

having come one from a big acute care hospital where this was not the case, it seems strange and unethical to me. Anyone else see this policy where they work? Thoughts?

Sour Lemon

Has 9 years experience.

This is a new one for me, so I'm wondering how prevalent this is.

I work in an LTACC, that is based within a host hospital. In order for our patients to have any surgical procedure, they have to be FC.

Lots of times we send a pt down for surgery, that requires intubation, they fail to wean, and we get them back a few days later, still intubated or trached and pegged. Often said patient was DNR or DNI prior to surgery, and they get re admitted to us as FC.

having come one from a big acute care hospital where this was not the case, it seems strange and unethical to me. Anyone else see this policy where they work? Thoughts?

I've only worked in acute care and this has been the case at the three hospitals I've worked at. DNRs were/are required to be suspended for surgery. I always assumed they were back to their original status after surgery, but being in med/surg, patients with outcomes as bad as the one you describe would not have come back to me post-op. Interesting scenario.

That's so weird to me. I know my old hospital, I sent a patient down for surgery, as a DNR, his blood pressure tanked and they weren't able to bring it up and he "expired" in the OR. My concern is that the code statis isnt reverting post op. Right now I have a PT who I know was adamant DNI with an ET tube. I sent her to surgery, so I know she was pretty particular on this and her daughter, who is signing authority, was supportive of it.

the surgeons don't want the death on their record, you know the saying "no one dies in the OR"...

the surgeons don't want the death on their record, you know the saying "no one dies in the OR"...

Nor should they, now that we have decided to potentially crucify their reputations for same.

I can top that -- in the large academic healthcare system in which I currently work, anyone who comes in as a suicide attempt is automatically a full code, even if that person has had a legitimate DNR order for years. It's automatically voided by any attempt to harm yourself, as far as my employer is concerned. I don't know if that's a state-wide thing or just my employer.

roser13, ASN, RN

Specializes in Med/Surg, Ortho, ASC. Has 17 years experience.

In our ASC where all surgeries are elective, no one is a DNR. Even though we ask for their Living Wills (Medicare requirement?), they will not be honored.

AJJKRN

Specializes in Medical-Surgical/Float Pool/Stepdown. Has 6+ years experience.

Where I'm at the patient is a full code for 24 hours after their surgery then their previous code status resumes (after the MD follows up and changes it back anyways).

brillohead, ADN, RN

Specializes in Cardio-Pulmonary; Med-Surg; Private Duty. Has 5 years experience.

My hospital has "levels" of code status: Full Code; Intubation OK but no CPR; No Intubation or CPR but Meds OK; and Comfort Care Only.

In order to go to surgery, they have to at least be changed to "Intubation OK but no CPR" because they can't intubate them for surgery without that change.

I'm not sure what happens with failure-to-wean patients in my facility, but I would hope that if they regain consciousness they can indicate their desire to extubate and resume DNR status, or if they don't regain consciousness, that their Patient Advocate or Legal Guardian or Next of Kin would be kind enough to make the right decision to extubate and resume DNR status.

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 15 years experience.

This is a discussion that should be taking place between the surgeon and the patient, the anesthesia provider and the patient, and as a team. In any acute facility, the order for a DNR must be written/entered. Orders from another facility don't qualify. Now, if someone were to come to surgery with a DNR order, there is often a discussion with the anesthesia provider about the use of reversal agents and certain terms for remaining intubated. Many patients simply rescind the DNR during the surgical period. Others are agreeable to pretty much anything but actual compressions.

Fiona59

Has 18 years experience.

We honour their status. If you came in with goals of care, we honour it.

If you die post op, there is an autopsy.

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory. Has 39 years experience.

I can top that -- in the large academic healthcare system in which I currently work, anyone who comes in as a suicide attempt is automatically a full code, even if that person has had a legitimate DNR order for years. It's automatically voided by any attempt to harm yourself, as far as my employer is concerned. I don't know if that's a state-wide thing or just my employer.

That's bizarre. What's the rationale?

Jolie, BSN

Specializes in Maternal - Child Health. Has 34 years experience.

That's bizarre. What's the rationale?

My guess is that individuals who have attempted to kill themselves are not considered legally competent to make their own treatment decisions.

See that makes sense, but requires a HCP to follow up. We've had to fight our MD's before to resume code status.

It does kind of make sense.

The salvageability of a pt in surgery is very different than in a LTC.

AFAIK, a brief code with full recovery is not all that unusual. And to have somebody go to surgery, then prevent the surgeon or anesthesiologist from rescuscitating doesn't make a lot of sense.

But, on return, when it starts becoming obvious that Grandma won't be making it home for Christmas, their wishes should be honored.

My guess is that individuals who have attempted to kill themselves are not considered legally competent to make their own treatment decisions.

Nope, they don't automatically lose their ability to make any other kind of treatment decision. No one's really been able to explain it to me in any way that makes sense.

What about palliative type surgeries?

I had a patient whose pre op note prior to undergoing a debulking for pain relief literally stated that it would be merciful for the patient to die under anesthesia.

Nope, they don't automatically lose their ability to make any other kind of treatment decision. No one's really been able to explain it to me in any way that makes sense.

It's hard even for "thinkers" to make sense out of these things because too often the rationales given to nurses are just someone's idea of something; rarely do we get the benefit of knowing how/why a legal or ethics committee came to the conclusion. And worse, we often get a superior's "take" on it (or their own emtional reasoning). I do not know the answer to this one but I think (right or wrong) it goes something like this:

We know that we allow LEOs to compel the person who expresses suicidal ideation/intention to present for evaluation. They legally can take people into protective custody and present them for evaluation. At the hospital, we can legally compel you to stay until we evaluate your situation. We also know that we hospitalize patients (sometimes involuntarily) because they have verbalized an intent to kill themselves. So, our legal system does support this idea that we as a society have an interest in trying to prevent people from killing themselves, and when we are aware of their intent to do so we legally take steps to prevent them from doing it - steps that can be considered fairly extreme if necessary (involuntary hospitalization).

If we have a suicidal patient in the hospital, we will enact precautions to prevent suicide attempts while hospitalized. Why do we do that - well (aside from the obvious liability issues), we do it because we have a societal value that we should do all we can to prevent people from voluntarily killing themselves, especially when we haven't had the opportunity to thoroughly assess judgment and insight or provide any assistance or rule out medical issues that may be contributing. All that to say that when no measures have been taken in attempt to determine whether the decision (to kill oneself) is being made in a sound state of mind, we (legally) make attempts to stop them from doing it.

The person who has already made the attempt and now is being presented for resuscitation is a bit of a different situation than a patient who presents for care in a suicidal state, but it seems like similar principles of care are applied (we will do what we can to not let you succeed with your intent to kill yourself) - - I am making no declaration or judgment about the correctness or incorrectness of this, I'm just saying I think these are some of the underlying ethical and legal points that an ethics committe would consider, and that probably have something to do with 'all patients who attempt suicide are full code.'

Right or wrong, I think the reason that we don't honor a DNR when one is found in extremis following suicide attempt is because we also don't/wouldn't legally "honor" your statement that you want to die when you are alive. Instead, we take direct actions against it. The laws of our society still support the idea that we can compel you for a mental health evaluation and take measures to ensure that you don't kill yourself up to that point.