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Full Code required for surgery?

Nurses   (3,213 Views | 30 Replies)
by KDPatty KDPatty (New) New

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Jolie is a BSN and specializes in Maternal - Child Health.

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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.

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

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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.

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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.

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3,726 Posts; 23,845 Profile Views

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.

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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.

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22 Posts; 715 Profile Views

The only surgery for which I've seen full code required for us is open heart. Otherwise, as far as I know, patients stay DNRs.

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Jolie is a BSN and specializes in Maternal - Child Health.

6,373 Posts; 35,059 Profile Views

Nope, they don't automatically lose their ability to make any other kind of treatment decision.

I respectfully disagree. To my knowledge, most if not all patients who have attempted suicide are placed on a psychiatric hold. That in and of itself is a loss of their ability to make decisions. They are not allowed to refuse admission or demand discharge.

Once admitted, they may refuse medications, treatments and therapy, but to my knowledge, there is no treatment decision other than a DNR that could predictably result in the patient's death.

JKL33's explanation is far more elegant, but I believe s/he and I are essentially saying the same thing.

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RNOTODAY has 18 years experience as a BSN, RN and specializes in NICU, ER, OR.

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Correct, there are no DNR/I in the OR, its suspended until I believe Post op day 3 but don't quote me... lol I work in the OR, all I know is that there is no such thing as a DNR

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RNOTODAY has 18 years experience as a BSN, RN and specializes in NICU, ER, OR.

1,116 Posts; 21,277 Profile Views

Every patient is a full code in the OR/- a DNR is temporarily suspended

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Rose_Queen is a BSN, MSN, RN and specializes in OR, education.

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Every patient is a full code in the OR/- a DNR is temporarily suspended

Perhaps in your facility, but it is not universal. My facility does a very thorough interview and usually the patient will agree to have certain portions of the DNR suspended, such as defibrillation during heart surgery, the use of reversal agents, etc. But for a patient who wishes to remain a DNR, they will still be a DNR.

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I respectfully disagree. To my knowledge, most if not all patients who have attempted suicide are placed on a psychiatric hold. That in and of itself is a loss of their ability to make decisions. They are not allowed to refuse admission or demand discharge.

Once admitted, they may refuse medications, treatments and therapy, but to my knowledge, there is no treatment decision other than a DNR that could predictably result in the patient's death.

JKL33's explanation is far more elegant, but I believe s/he and I are essentially saying the same thing.

They lose their right to choose to leave the hospital and to refuse admission to a psychiatric facility if that is deemed necessary by the psych people who evaluate them after admission; however, as I stated (and as you stated), they don't automatically lose the right to make decisions about their treatment while in the hospital (or in a psychiatric facility -- the involuntary commitment laws only legally compel people to be detained for evaluation; they don't require that people participate in the evaluation, or permit people to be treated against their will without further legal proceedings).

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