The Slow Code: Justified? - page 4
I have been a nurse for only seven years; however, certain events and situations will remain embedded in my memory for the rest of my life. One of these events took place during my first year of... Read More
Dec 6, '12my grandmother (who is 85) saw HER mother ventilated and begging to go, and signed her own DNR/DNI - and that was 20 years ago at 65 years old...she lives with my mom now and that AD is parked in the cabinet with her medications - and we all know we DON'T attempt to bring her back - she doesn't want it...I went so far as to tell my husband where it is if he ever checks on her and finds her...
best thing she ever did for herself...at nearly 40 I'm not ready to do that (my kids are still young) but you betcha when I hit 65 or get diagnosed with something terminal that will be the first signature I make!
Dec 6, '12Quote from Jean Marie46514Jean marie- thank you for responding to me in such a respectful manner. I have to admit i was a little worried about putting such a personal post up, especially because i do realize i am inexperienced as a nurse, and not all patients are in a situation similar to my dads. So im grateful I didnt get shut down for posting it from my point of view. I guess i just hoped putting it in a different light might make some double think the situation. And your right- there was more to it than the three heart attacks but i was just trying to quickly explain it.To NurseyNurse, i am not sure that most ppl would view someone whose had 3 heart attacks as "terminally ill", etc.
A patient in his 40s, 50s, or 60s, who is saying (whether the person is quoting their doctor correctly, or incorrectly---as sometimes happens...)
that they've been told they have 6 months to live, is not quite the same as someone actively dying or definitly, unquestionably, terminally, fatally ill and suffering. I'd think every nurse i know
would have rushed to save your poppa, indeed. all out efforts, prolonging that code til our arms ached.
If it comforts you any, never ever, in 3 decades, have i EVER ever witnessed a slow code on anyone who wasn't already in the process of actively dying, or very terminally ill, or suffering extremely in fatal end-stage disease processes. Might have happened, but, i've never ever seen it.
I've participated in some awesome saves, indeed. Sometimes, we do get back the person who just arrested, oh yes we do!! sometimes, the whole person comes back!! I might have helped bring your own dad back, who knows. I am quite passionate about many many codes, and very devastated when the codes don't work on very viable people.
It just breaks my heart to code the terminally ill, the extremely elderly with a lotta suffering going on, being robbed of their chance to have a peaceful death. The aftermath there, can be horrific to watch. i hate it when my heart dislikes what my own hands are doing.
I so so share your idea that more ppl (even you young ones out there!!) should have legal living wills. Takes 10 minutes, is not expensive to do, and can be more of a comfort to those you leave behind to decide,
than you'll ever know.
Although i hate that you've felt this way, i like the way you explained this: " i hate it when my heart hates what my hands are doing. " that definately gives me something to think about. With my limited experience, i may be blind to the reality of alot in nursing. I welcome hearing someone such as yourself teach me to broaden my thinking. I fear the day i have to revive a patient who truly is ready to go, but other people/family dont see that and cant let go. But i hope we could take that empathy for this suffering patient and use it to help educate the family or refer them to someone they may listen to. I hope i handle it as well as most nurses. I just feel ill never regret acting according to families wishes and i do think id regret acting against their wises, no matter how wrong they may be. Its their loved one, not mine. But we are the patients' advocate. So i guess ive got a lot to learn!! Even as i type this, i cannot think of the "right" answer, so i go back and forth. I guess you do the best you can in each unique situation. Thank you for your time!
Dec 6, '12Ill also never forget how once the emts or doctor seeing my dad for the first time in er acted once they heard of his past medical history. It was almost like they just quit trying as hard as they were before finding out. So maybe im just biased based on my limited familial experience. Which i am going to aim very hard not to be during my career. But my mothers also a nurse, and she noticed the same as me. OTOH- ive heard her talk about how sad it is that one of her pts family just wouldnt let go, when her patient was done and suffering. I think every case is individual and hopefully when the time comes, ill do the right thing.
Dec 6, '12Ok one last comment- as i went back and read these posts again, it reminded me of something. When my father finally did pass, the doctors and nurses pulled is aside, and stated: "we tried everything we could. We kept going and going for as long as we could." While it may be naive, at that point in time in my grieving, that gave me tremendous comfort. As me and my mom are both nurses, i think we both had the thought that if we were there, we might have saved him. Just because we had saved him numerous times before. In a way im grateful that i didnt have to, i didnt want his death in my hands. But i still think, what if? So i truly truly hope that when they said they did "absolutely everything they could", they meant it. Id hate to think that its just something they say to everyone (while im sure they do, i just hope its true). People put soooo much trust in their healthcare providers to do the most they can. We cannot violate that trust.
End rant. Thank you all for listening and reading! I apologize, but this post really spoke to me. I guess its something i feel passionate about. Take care everyone!
Dec 6, '12We've received patients in who have been down for far to long to have any hope of resuscitation, let alone any sort of positive outcome from ROSC. There's definitely less of a sense of urgency when we ran those codes. We weren't slow, and we ran the code the way it needed to go, but people were calmer, less anxious. No yelling from freaked out junior attendings who were feeling suddenly and completely in over their heads. These were patients who probably should have been pronounced upon arrival to the ED rather than worked.... those codes were run more for the family (to show that we did everything, to allow them to be there for the "death" that really, had occurred a while ago).
I agree that slow codes are unethical, but I also am not completely convinced of the ethics of keeping people alive at any cost. I wonder if more people would choose to limit heroic measures for themselves or their loved ones if they knew that a "successful" resuscitation doesn't mean saving what makes that individual themselves.
Dec 6, '12Quote from RFarleyRNIsn't CPR an attempt to defeat death? How much more against God's will can you get than to give someone life once it is taken away?We are not to play God with anyone elses life.
Dec 6, '12I'll agree that, by definition, it's unethical not to "go all out" on any pt who is a full code. I must concede that. But I'm surprised so many here seem to see things in black and white. It's not as simple as "they're full code, therefore let's start full CPR" when you're dealing with a 95 year old little old lady who is dead and not coming back as a human being ever again. There ARE cases where "less than 100%" codes are justified.
Dec 6, '12btw, i had to leave home, and while driving away, this dread came over me, "oh no!! That's right, there are even student nurses, nurses of all types, who might read my posts, and at some code set up, decide on her own, to do a slow code."
and i want to say, as much as i hate seeing my own hands doing stuff i dislike, i wouldn't risk my license over this, nor risk getting arrested, to all you young ones out there reading along. coworkers come in all kind of mindsets. My point is, I don't want to get anyone who is in over his/her head in trouble somewhere.
but, having spent a lifetime caring for the "saved" ones, i'd be last person in the world to act righteous to some group who did a slow code on a terminally ill person.
But, thinking about this, discussing it openly,
could have positive outcomes...
hopefully will get everyone reading along--OF ANY AGE---to fill in a living will. It might even give us more courage to discuss this with patients and our families. (again, standing there saying, "but, but, my husband would not want to be kept alive on a vent brain-dead!!" won't always solve the situation, without a legal living will.)
Filling in a living will does NOT NOT NOT mean you are saying you do not want to be resuscitated. It means YOU choose in what circumstance you do, or do not, want to be brought back,
or, what all life-sustaining measures you would want done to you, if you were in a vegetative state, etc. There are MANY OPTIONS on a living will, for various scenarios.
Dec 6, '12elkpark:
If it were up to me, I would make the national standard that everyone is a DNR unless there's some darned good reason to resuscitate them (y'know, young, healthy adult, some freak accident with electricity that stopped the heart ... )
I've heard of wrongful death and wrongful birth suits before. What about wrongful...life? vegetation? assault and battery? What should we call it when we "bring someone back" only for them to die a slow death later?
I don't know...maybe down the road, as more evidence is accumulated, the ACLS/BLS protocols can change so as to cut down on this stuff? Such as, unwitnessed inhospital arrest with PEA, no pulse after 2 rounds of epi/CPR, end the code....we'll see. The way things are I think that's our only chance to cut down on all this suffering and waste.
Dec 6, '12Quote from Jean Marie46514btw, i had to leave home, and while driving away, this dread came over me, "oh no!! That's right, there are even student nurses, nurses of all types, who might read my posts, and at some code set up, decide on her own, to do a slow code."
YES!! This is exactly what I was thinking and trying to say at the end of one of my posts. But I would hope someone reading this would be smart enough to not do something just because they read it online. Thats also what I meant when I said, "they may not have the same decision making process that you do."
Dec 6, '12Just a couple of weeks ago, there was a little lady on my unit, 92 years old, who died while sitting in her wheelchair in the dayroom. This lady was hospice, very chronically ill, had no quality of life whatsoever, and in most everyone's opinion should NOT have been a full code but alas, she still was. She was therefore pounded on, crunched up, for no reason as she was very much GONE. She could have went so peacefully, just sitting there in her chair, with dignity, but instead a code was called.
Later on, some coworkers and I were discussing the situation and we came to the conclusion that so many families do not understand this key thing: if a resident is made a DNR, we are still going to treat them and give their life as much quality as we can. If they get sick and have a fever, we are going to give them Tylenol. If they have symptoms of a UTI, we're still going to call the doctor and get antibiotics ordered; we're not going to let them lay there and get septic and just die. "DNR" does not mean, "do not treat". Some families do not get that.
Dec 6, '12wow, NurseCard, that is such a great point, i think you've hit on something there. I do think you just nutshelled one fear that keeps some ppl from signing a DNR form...probably the biggest fear of all, i bet.
i think another reason, is, ppl feel it's "giving up" so so much talk of "fighters" that fighting for a peaceful death, doesn't get enough credit, maybe sometimes.
i think another reason, could include just misinformation about what a code is really like, and how much of the brain is saved, (usually not much) if we do get the person breathing again.
but yeah, NurseCard, i think you hit that one on the head all right, l think some ppl do think, "Aw geez, if we allow Grampa to be a DNR, he'll just not be cared for or treated."
Dec 6, '12Quote from PMFB-RNWow. Shocking. I'm shocked that you can slow a code or do a "show" code without proper documentation. Unless I had documentation of the patients' words verbatim in the chart or a DNR note, I would have fully coded the patient. Trust me, I know the feeling or not having the proper paper work and going against the patients verbal wishes. However, if there is no documentation then I have to follow policy and procedure and the nurse practice act.OK I am going to disagree. A proper slow code is an art. How to make it look like you are doing something when not really trying to save the patient. As far as I am concerned the slow code will be needed as a self defence mechanisim for health care providers so long as our society maintains it's irrational refusal to talk openly about end of life issues and accept that dying is part of life.
I am a full time rapid response nurse. I am the code administrator for my hospital and the alternate code team leader until / if the "code chief" (usually a senior med or surg resident) arrives on the scene. Occasionaly I will run the entire code like the few times there have been two codes going on at the same time or the code chief doesn't show up for some other reason.
ON several occasions I have refused to code a patient at all. Other times I will let the team know this is going to be a a "show" or "slow" code. In every instance I had reason to know the patients wishes and knew that being coded was aginst their wishes. For example one man with severe necrotic bowel, literaly rotting from the inside out did not wish to be coded. When he was alert and oriented early in his hospitalization he made the informed decision to be a DNR. Later, when he could no longer make his wishes known, his estranged wife changed his code status to full code. The real problem is that she would be allowed to do that at all. That his weak kneeded-fearful-of-a-lawsuit physicians agreed to the change in his code status is another major problem that needs to be adressed. However all that is water under the bridge when "code blue" is called on him.
If the patient has made an informed decision to be full code I will code the heck out of him. I will not go aginst a patient's informed decision and wishes. I hope it doesn't cost me my job (so far not an issue) but if i does it does.
When I worked in bedside, I always asked my patients if they prefer DNR or full code and would document the convo and notify the MD so that changes would be made.
This is one of the things I hated about working in ICU.... not being able to follow patients' wishes due to lack of documentation and follow up.