To code or not to code, that is the question

Nurses General Nursing

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Specializes in MICU, SICU, PACU, Travel nursing.

So I work in ICU and last night I took care of this lady who was 84 years old and had come in earlier that morning with acute abdominal pain x 1 week. She was admitted to floor, got shocky with low BP and high HR and very distended belly and was transferred to us. Stat EGD showed lots of impaction and fluid build up. When I arrived to work the night shift we were getting ready to send her to emergency surgery. So I get her to surgery and less than 2 hours later they call and say they are on their way back right now and that things went really poorly. She coded on the table and her bowels and other organs were blue. She had toxic megacolon apparently. Although she had no perfusion which means no O2 sat or BP for over an hour, she was externally paced and vented and had a paced heart rate and a dopplered pulse in her right fem. So they left me with this blue lady, with fixed puplis, no reflexes, flaccid, temp 34.7, no sat or bp. Family(who lives across country and is not here) wants everything done (sigh).Docs come in and write pages and pages of orders and I maz her out on Levophed and Epi drips and start a bicarb drip and push bicarb and transfuse and the whole nine yards. I get the crash cart in the room and wait. And wait. And wait. And somehow, the lady manages to keep a pulse the whole night and of course the heart rate courtesy of the external pacemaker.But thats all she keeps, there is little to no BP and sats only read off and on the whole night. So I figure the docs are all very aware of situation as I have been on the phone with them all night and I think I have done everything I could possibly do. But then an OR nurse who dropped her off comes in to check on her in the morning as I am leaving and cant believe she's still alive. She asks why I havent coded the patient because even though she has a pulse, she isnt perfusing so shouldn't we have coded her??I mean she was nice about it, but I really got a little offended because I had been running my tush off all night and I didnt like her suggesting that maybe I should have been doing things differently.

So my question is should I have coded the lady? The nurse I reported to seemed okay. The docs all knew the situation. Other than standing next to her doing constant CPR the whole night, not sure what else I could have done?? I mean I know that the epi and levophed are the only reason she has a pulse, but still its there. I have never heard of coding a patient strictly to perfuse if a pulse and heart rate and ET tube are in place. Would any of you nurses out there done different in my situation? I am curious and would appreciate all responses.

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Specializes in Post Anesthesia.

I can't tell you the number of times I have been in exactly your situation. The only thing you can do is get clear and specific instructions from the attending. As a rule I call a code whenever SBP sustains below 50 or so, but in this ladys state, you are right-what would an hour of CPR have done for her. When I anticipate this type of night I ask the attending at what numbers he wants a to be called, and at what point do we start CPR. If the answer is do not code then I insist he at least write that as an order- we have the protocals in place for DNR with full medical management. Without that you are at terrible risk of some family member showing up 12hrs later and demanding (followed quickly be attorneys) why you did not do CPR and save her great aunt that she hasn't seen in 40years.- You see, she has seen every episoode of "General Hospital" and "SCRUBS" and knows that chest compressions and "those paddle things" always bring the patient back. You have also just placed a winning lottery ticket in the hands of any family member with a few too many bills and a little extra time on thier hands willing to play "Malpractice Bingo" for big bucks. For the sake of your licence and the financial security of the hospital I think I would have called a code. Your patient couldn't have cared less-she was already in a much better place.

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Specializes in MICU, SICU, PACU, Travel nursing.

Thanks for the response. Its always pretty tricky in these circumstances. But in this case the attending and critical care doc were at bedside and very aware that there was no perfusion and I was told to "just keep doing what I was doing", and that we were already doing everything we could. The critical care doc said to code WHEN we lost the pulse, only we never did. I had the charge nurse involved and also aware and she agreed that if the docs were ok with the way things were just code her if she loses the heart rate or pulse, which she did not. There were no family present, we were just talking to them on the phone. I wish they would have just called the 1st code off and not left her externally paced, as she had no underlying rhythm and could have died peacefully. But I guess that messes up their numbers when they die in surgery, better to ship the corpse to ICU on a vent and pacer I guess. But yeah I hate how families dont understand situations like these.

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Specializes in Post Anesthesia.

Since you had a doc at the bedside- at least you are in the clear. I DO believe they acted appropriately for the circumstances but they are still taking an awful chance with an understanding family by not doing chest compressions when there was no BP high enough to be perfusing the vital organs. Admittedly there was no reason to perfuse the vital organs but I do hope there isn't a $$$ hungry family member willing to make a few bucks at the hospitals expense. A DNR/FMM order would have been most in order.

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Specializes in MICU, SICU, PACU, Travel nursing.

You are so right about that. I was so disappointed not to get a DNR from the family when the docs talked to them on the phone, it would have made me feel alot more assured. You just never know about these families. In her case, I don't think anybody was planning on coming out as far as I know (they lived on the other side of the country). But people will sue over anything nowadays so I get really paranoid about charting and double guessing myself in these kinds of situations.

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Specializes in Med/Surg.

I hope this lady passes over before her family arrives. Poor baby, she doesn't deserve to be kept alive artificially.

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Specializes in Adult Cardiac surgical.
Since you had a doc at the bedside- at least you are in the clear. I DO believe they acted appropriately for the circumstances but they are still taking an awful chance with an understanding family by not doing chest compressions when there was no BP high enough to be perfusing the vital organs. Admittedly there was no reason to perfuse the vital organs but I do hope there isn't a $$$ hungry family member willing to make a few bucks at the hospitals expense. A DNR/FMM order would have been most in order.

I am not sure this family would have a case that would hold up in court. This pt. is 100%paced and already tubed. As long as the levo/epi gtt maintained BP that was ordered and of course GOOD documentation--i.e pt had fixed pupils, no gag upon arrival from OR......no 0s sat...etc, etc

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Specializes in Trauma ICU, Surgical ICU, Medical ICU.

Seems like you did as much as you could do. I dont really think doing any more would've helped the situation. I HATE these situations!!! Families often just dont get it. Sounds like you had a bad night. Our unit wouldn't have coded in this situation either. Maybe this question was answered, but the family, were they there or did you just talk to them on the phone? Sounds kind of wierd that they didnt even come in when the family member was so sick. Was there a reason? Anyway, sending you lots of love for a bad night!!!

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Specializes in ICU/CCU, Rehab, insurance, case manager.

first of you did everything right, **you do not code or do CPR on someone with a pulse, that is BLS 101**. you do CPR on a infant if bradacardic not a adult. someone that hemodynamically is shutting down and loaded with pressures such as levo, vaso, neo and there BP is still not reading is SOL. you just keep the gtts going till the heart stops then you code then. you doing CPR on some with a pulse is whats gonna get you in a sling, i have to say susan that scares me you wrote that.

Jamie

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Specializes in Peri-op/Sub-Acute ANP.

Ditto everything said above, but I couldn't help thinking that you wouldn't have second-guessed yourself if the OR nurse hadn't come in to "check on her".

Correct me if I am wrong, but the lady was no longer her patient and the RN really had no business coming to check on her, or ever-so-nicely question your judgment.

Just ticks me a little that someone who should know better would question your actions when she had to know that you did all you could do given the circumstances - no doubt the OR team that she was on were similarly impotent in this case.

Maybe I'm being a little harsh on her. I get that we often want to know how our patients do, but there was no need for the guilt trip is all I'm saying (intentional or not).

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Specializes in CVICU, Burns, Trauma, BMT, Infection control.

Wow,on so many levels,so many people let you the nurse and this pt down. :uhoh3:

A pt with no discernable neuro response, no appreciable b/p w/dead organs is already gone.Only pacer/gtts keeping her clueless body barely plugging away.Your charge should have insisted on a DNR order before the docs left. They(docs) left you in a vulnerable state,they took advantage of you I'm thinking because you haven't been there long.I don't think you can be faulted though. Hopefully you documented well. But you didn't let this lady down,the docs did by rushing her off the OR table so as not to screw up their stats.:nono:

And FYI,if you have a pt w/ a pulse who's B/P is less than 50 systolic you can pretty much start CPR on them b/c they will not be perfusing/awake and their rhythm will probably already be deteriorating to a V Tach/fib.

And the OR nurse dropping by with her 2 cents,pretty much uncalled for.

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Specializes in MICU, SICU, PACU, Travel nursing.

Thanks to all who replied. I am fairly new at this facility and felt that the situation was less than ideal and pretty sketchy. Luckily I have had some off nights to destress and get ready to go back in later this week. I am hoping for some boring nights sans legal/moral/ethical end of life care dilemmas. After reading all replies I feel a little better and am not doubting the care that I gave anymore. I did the best I could under the unclear circumstances. I think the patient was gone some place better long before she came to me and I dont think she suffered any under my care. Heres hoping for some boring nights when I go back!!

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