Palliative Patients Who Are Full Codes

SunnyAndrsn · Nov 2, 2010

I can understand the confusion, it seems to be contradictory to be on palliative care and be a full code. Do the patients actually understand the gravity of their illness? Do they understand the futility involved if and when they code? What is their reasoning for wanting to remain a full code if they have a terminal prognosis?

It seems to me that the patients are in denial, which is a stage of the grieving process. Until they are able to accept their prognosis, they likely will want to remain full code status.

My primary job is in long term care, and when we have residents and/or families who are unable to accept their loved ones terminal situation, we ask our MDs to discuss this with the family/resident. We have a really great staff MD who is able to have very realistic discussions with families and pts. Most of the time, this works. We do still have a few who remain completely unrealistic, despite the fact that we would break virtually every rib if we did CPR on them.

Let me first begin by saying that I believe that everyone has the right to choose what they want to be done for end-of-life care. And as a health care provider I respect these choices, no matter what I think.
I have been thinking a lot about ethical situations at work, and I have come across one that seems to strike a different chord with nurses and physicians alike. It seems to me that lately at work (medical floor), a lot of our palliative patients with a prognosis of less that 3 months are full codes. Because of this, a lot of nurses have different opinions about what is going to happen when the patient actually codes. Such as, doing a "slow code", ie: no one reacts as if there is an emergency, allowing the patient to pass on. Others think that calling rapid response with any significant change in the patient would effectively take the code situation "off our hands". And other nurses think that it should be treated like any other code. (I tend to agree with the latter)
Nurses, students, anyone at all... I am simply looking for some insight, opinions, experiences to develop my own learning through you.
Thanks in advance,
Sabrina

Hoozdo, ADN · Nov 2, 2010

Legally, the situation is full code or DNR.

There are only two choices, thus only two responses. Why muddy the waters any

further?

I don't know if this is state law or federal law though. That is how it works in my

state.

I would never "slow code" any patient that is full code. You are opening yourself up for a law suit or loss of license.

Zookeeper3 · Nov 2, 2010

THis is unfortunately common in our ICU. Many MD's have a difficult time discussing end of life/DNR with patients and or family just the same as nurses. After working many years, I'm very comfortable with the discussion. I spend quite a bit of time while I'm providing care just discussing treatment options. Although I'm a huge advocate of death with dignity and comfort, sometimes I have to "torture" someone by trying to revive them, to expect them to die of thier disease in a few days or shorter! :mad:

If it's the patients wishes to fight until the end, it's so much easier as long as they understand how futile it is. When it's family that is going against the patients wishes... I do everything to keep them in the room as we code and respectfully remind them that we can stop coding at any moment they tell us to. Unfortunately it takes family to actually "SEE" what is being done to thier loved one before they will stop full code efforts and allow them die. It's a very difficult and many times an unethical situation, where we can only keep teaching and offering options, in hopes that a death with peace and dignity will result.

Consider asking your educator for some death and dying inservices by a professional. The ones I've attended have given me excellent ideas to say the same things in different ways for different types of family dynamics. Not suggesting you're not doing a good job at it, only that it can't hurt a difficult situation.

tyvin, BSN, RN · Nov 2, 2010

"There are no mistakes, no coincidences. All events are blessings given to us to learn from" (Elizabeth Kubler-Ross).

If it's a code, it's a code.

classicdame, MSN, EdD · Nov 2, 2010

no one codes alone. Whom do you trust enough to risk your license?

OttawaRPN · Nov 2, 2010

I surely don't understand the point of being palliative and full code, thankfully none of the docs I work with would stand for this ambiguity... not to mention this leaves the nurses with a huge potential liability on their shoulders... do we? ... don't we? Advocating for best practice means contingency plans are firmly in place to include procedures for all possible eventualities and probabilities. If your workplace doesn't have one, push for it.

As for "soft" code... what the heck is the point?

Zookeeper3 · Nov 2, 2010

Unfortunately in the US it is more confusing. Family is allowed to say.. drugs yes, no cpr, cpr... don't add more pressers... max the pressers but don't difibrillate..... defib... but no cpr. THAT is what the US doctors write for and is allowed, however unethical. This lets the doc off easy and the nurses left to deal with the fall out of a death without dignity or a quality death. For some reason we are fearful of saying... "NO", "NO" we have done all we can do and now we will focus on comfort of your loved one. We will NOT let them die in pain and will not let them suffer. Our doc's and staff, and FAMILY fail at making this happen and we semi code, muck it all up because no one can get on the right page.... all despite good nursing efforts... Once the crazy eight ball gets rolling... the mess ensures.

I surely don't understand the point of being palliative and full code, thankfully none of the docs I work with would stand for this ambiguity... not to mention this leaves the nurses with a huge potential liability on their shoulders... do we? ... don't we? Advocating for best practice means contingency plans are firmly in place to include procedures for all possible eventualities and probabilities. If your workplace doesn't have one, push for it.
As for "soft" code... what the heck is the point?

aileenve, ASN, RN · Nov 2, 2010

How about an order that says 'DNR- but can intubate"!!

nminodob · Nov 2, 2010

There are also patients who are "limited codes" - only pressors, no intubation, or some other combo like that.

sabrina_RPN · Nov 2, 2010

Thank you for all of your comments. I can tell you that if a patient codes, I will be doing everything that they want done, and nothing that they don't want. I very much appreciate all of your input.

Thanks,

Sabrina

Caffeine_IV · Nov 2, 2010

Occasionally when we have a terminal pt who is a full code...it's because the MDs have "forgotten" to address it with the family.

Other than that, the family is in denial and unfortunately the patient has not made their wishes known before they deteriorated.

I remember during my orientation someone called a code on a DNR and I have no idea why they did (maybe she forgot?).