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Patient Advocacy and CODE STATUS?! Need feedback please!

Has 10 years experience. Specializes in CV-ICU, Rehab, Med-Surg, Nursing Home.

Hello Everyone,

I was just wondering if anyone can offer any information regarding the legal and ethical concerns of initiating code status in dying patients. I currently work on an inpatient oncology unit where I feel code status is often taken lightly. I have observed physicians come out of a room and state, "Well, that patient is lucky if he's got 6 months". Or they will often say that a patient has a fatal condition, but 'little do they know' how severe it is.

This astounds me as a nurse. My heart aches for these patients and their families. Perhaps if they were better informed then they could complete their advanced directives and be more prepared for the inevitable. I see them wasting away in a hospital room when they could be spending their last moments in the comfort of their own home. I've seen families who, because they didn't know how serious their loved one's condition was, missed out on spending more time with them in their last moments.

As a nurse I feel that I have little to no control in changing this. I have had physicians ignore my pleas to inform the patients and their families or initiate code status despite knowing that death was likely near.

Does anyone know what the legal scope of practice is for a nurse in terms of discussing code status with patients and their families? I have had nurses tell me that I cannot bring up the topic until the physician does. And often times when I do suggest this to the physician, I am ignored or made to feel belittled for requesting it. This makes me feel as though I am not being a good patient advocate. Any feedback would be appreciated. Thanks!

nurseatheart81 :nurse:

I am lucky enough to work with a Dr. who agrees with DNR status with most of the pts. who need it. But!!!, I am limilted by the pts, family who often do not know what a CODE is! There seems to be a problem as to who informs them about what a CODE is. Social Services usually ask this question.....Do you want them to be a Full Code. No one tells them that the pt. is already dead when they call a code! That it breaks all the ribs and may pucture the lungs. No one says that if they come back they will be one a vent and never be what they were before! Unless you are ready to put a person on a vent and a peg tube,.....why do you want a gravely ill person to be a full code?

FYI.. yes you can discuss DNR status and CPR

kstec, LPN

Has 1 years experience. Specializes in Geriatrics/Family Practice.

I don't know all the legalities in a hospital, but in our LTC facility we can talk about code status and quality of life at anytime. We don't need a MD to tell us what the patient and family have options to do. Some patients come in for rehab (medicare) and because of existing conditions besides the broken hip, knee replacement, etc, they end up getting real ill. Some are informed that they can go home and make the most of their time left. I always inform my patients of any information that I know is factual and give them any information they made need to make informed decisions. I don't know how many times when I worked family practice and internal med that the patient would say " I don't understand what he meant." I would then put the patient back in the room and tell the MD the patient has more questions or that they don't understand what you meant. Patients and their families have the right to be in control of their care and tx. I guess if your heart is in the right place when you are being a patient advocate, I don't know how you can go wrong. We as nurses are the middleman between the MD and patient and of course we may upset MD's sometimes, but when your patient is terminal, they won't get over it with the little time they have left, the MD will. Without us nurses most patients would be clueless as to their disease, their tx., and their options.

WolfpackRed

Has 4 years experience. Specializes in Nurse Anesthesia, ICU, ED.

One trend that I have noticed recently among some physicians is the accepted practice of "overriding" advanced directives. Lets say a pt comes to the hospital with PNA and full DNR/DNI status. These physicians will intubate the pt as part of the tx of the PNA. Or, if a pt is DNI and codes, one attending has told the residents/interns that it is ok to intubate that pt "as it would not be a successful code" if the pt had no airway.

One trend that I have noticed recently among some physicians is the accepted practice of "overriding" advanced directives. Lets say a pt comes to the hospital with PNA and full DNR/DNI status. These physicians will intubate the pt as part of the tx of the PNA. Or, if a pt is DNI and codes, one attending has told the residents/interns that it is ok to intubate that pt "as it would not be a successful code" if the pt had no airway.

Don't think that these are easy decisions to make, or that they are made flippantly.

Here's a couple things from my perspective:

(1) Most DNR/DNIs are poorly written. Usually the main statement is something to the effect of, "In the event my physicians determine that I have a terminal condition with no hope of recovery . . . " But what does that mean? We talk about survival rates, and few people ever have "no hope" of recovery. For example, patient has pancreatic cancer with a 2 year survival rate of 20%, then develops pneumonia. Do you treat the pneumonia and give them an extra 2 years? Or do you let them die tomorrow because they have a cancer that will kill them at some unspecified time in the future? What did they want? You don't know.

(2) Family members always have their own interpretation of what DNR means. I can't count how many times a daughter has told me, "She meant DNR if she had cancer or something, but in this case she would have wanted to live!" And maybe the daughter is right. Or maybe not. You just don't know.

(3) There is nothing worse than a "selective" DNR/DNI. I hate these Chinese menus some states use. "Oh, I don't want CPR, but I do what drugs, but no intubation, but you can shock me." What?! What?! Who came up with this garbage? It's total nonsense.

(4) Families will sue you for letting their relative die, but very few people get sued for ignoring them. Especially since most codes aren't successful anyway.

Basically, if people want to die at home, they should stay at home. Until people get better educated about what a DNR/DNI means, and there are more protections for us against angry families, they will continue to be routinely ignored.

gemini81sg

Has 10 years experience. Specializes in CV-ICU, Rehab, Med-Surg, Nursing Home.

Thank you everyone for the feedback so far.

To TiredMD: I recently had a patient's son (POA-HC also), tell me that he wanted his terminally ill father resusitated, but he only wanted us to do a couple of 'pumps' to his chest, but not too many because he didn't want us to put his father through any additional suffering...no really, I'm serious here! So I get your point about how confusing DNR/DNI status can be to patients and their families. After all, a couple of pumps isn't going to do much.

While I understand the part where you say that it is less liability to simply allow patients be a full code, I also feel that I have an obligation to at least initiate the education when appropriate. I have just always been under the impression that this was out of my 'scope of practice', therefore, I could not. I tried to find some legal and factual information on this, but was unable to find any on my state's (WI) website.

Again, thanks everyone for the feedback!

nurseatheart81 :nurse:

NurseyBaby'05, BSN, RN

Specializes in Neuro/Med-Surg/Oncology.

While discussing code status may or may not be in my scope of practice, I do broach the subject with many patients. We get the same ones over and over and they trust us. I'm try to be straightforward (in a diplomatic way, of course).

I said to the78 y/o end stage Multiple Myeloma pt whose body was shutting down more every week:

"Miss Suzy, what do you want us to do if we can't get you up? (After the 4th consective AM blood sugar in the 20s and teens) Do you want us to stick a tube down your throat, pound your chest, break some ribs and have you wind-up ventilated with a lot of complications or do you want us to let you go in your sleep?"

"Oh, I didn't think about that."

"It doesn't mean that we don't treat you. It would just mean that if we find you not breathing or your heart stops beating, that we just let you go then rather than bring you back for a few more weeks of your body shutting down slowly only to do it all over again. That would be cruel."

"Keep the idea in the back of your mind and think about it. Talk to Dr. XYZ and your family and see what you want to do."

Blunt to be sure, but sometimes we have been taking care of these people for years. I can't have that type of conversation with every patient, but in many cases, it's the first time they realize they have options other than all or nothing.

mama_d, BSN, RN

Has 10 years experience. Specializes in tele, oncology.

As a nurse on the other end of the oncology spectrum, working on the floor in the hospital where they often come repeatedly until they pass, I can reassure you that for me at least there is a lot of discussion of code status that goes on. Thankfully, by the time it gets to the end, most of our patients have opted for DNR with medical management initially and then transition to comfort care.

I also hate the selective DNRs..."Do CPR, but don't intubate". Um, yeah, someone is going to stand there and bag you without intubating you for the hour it takes to run the "code". My all time favorite was "do CPR, but do the compressions gently, b/c I don't want him to bruise." That one got a crash course in the mechanics of CPR. Or the family members who say "Go ahead and code them, but not if he's dead." Huh? Those are the ones who hear "You seem to be misinformed, a code is ONLY done on dead people."

You know those videos of people who have been in drunk driving accidents that they make high schoolers watch at prom time? Seems like sometimes it would be a good idea to have a video of actual codes for family members/patients of those who are imminent to watch to see what actually happens.

BoonieNurse

Has 16 years experience. Specializes in Cardiac, Skilled, Medical.

Before I became a nurse, my mother had been in a coma postop with sepsis for 2 weeks. On the 14th day (the only noc we had spent away from the hospital), my dad and I were awakened by a phone call that they had "coded" my mom. When we arrived at the hospital and I asked the nurse why they had done that, she replied "You didn't tell us not to".... we had NO IDEA that we had to do that. I ALWAYS make sure that my (very sick) patients and their families know that they have options. I feel that this is a moral obligation as a patient advocate.

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