"Limited Resuscitation"

wooh, BSN, RN · Jul 22, 2006

You can talk and educate until you're blue in the face, in the real world, people hear what they want to hear. Limited codes typically are the patient or family being not willing to give up, but not willing to be hooked up to everything either. I kind of think of it as a process. You get them to the limited code, let that settle in for a bit. Then you can work on them seeing the reality. Most limited codes I see are drugs only. Which is really no code (drugs won't do any good sitting in the pt's arm uncirculated.) But they give the family some peace that they "tried."

tridil2000, MSN, RN · Jul 22, 2006

You can talk and educate until you're blue in the face, in the real world, people hear what they want to hear. Limited codes typically are the patient or family being not willing to give up, but not willing to be hooked up to everything either. I kind of think of it as a process. You get them to the limited code, let that settle in for a bit. Then you can work on them seeing the reality. Most limited codes I see are drugs only. Which is really no code (drugs won't do any good sitting in the pt's arm uncirculated.) But they give the family some peace that they "tried."

the fact is you didn't try at all and to say you did is a lie.

you did NOT try to resuscitate anyone. you put epi in a vein.

call in your biothics team on these cases.

rninme · Jul 22, 2006

tridil

It is the patient's/family's choice! We do a very good job educating patients and families as to what a limited code will accomplish or rather NOT accomplish....the limitations of those choices.

Most of the patients that we admit with limited code status are elderly, have complicated chronic underlying diseases process, or are just plain tired of fighting the good fight. Again...it is THEIR decision. Most opt for airway with no intubation....I don't want to be on a machine. Or CPR with no meds....I haven't done a meds only code in YEARS!

I personally wouldn't touch the all or nothing approach with a twenty foot pole.

soliant12 · Jul 22, 2006

Yep it is the family's choice. Full code or no code those are the choices, end of story.

tridil
It is the patient's/family's choice! We do a very good job educating patients and families as to what a limited code will accomplish or rather NOT accomplish....the limitations of those choices.
Most of the patients that we admit with limited code status are elderly, have complicated chronic underlying diseases process, or are just plain tired of fighting the good fight. Again...it is THEIR decision. Most opt for airway with no intubation....I don't want to be on a machine. Or CPR with no meds....I haven't done a meds only code in YEARS!
I personally wouldn't touch the all or nothing approach with a twenty foot pole.

rninme · Jul 22, 2006

What fun!!:smiley_ab

The AMA doesn't agree. They support something called Advance Directives and Patient Rights for Self Determination.

Don't have the web address for you, sorry....but go to the AMA webpage...Ethical Decision Making...it discusses the need to respect patient's decision making in regards to life sustaining or life saving measures they wish to have pursued on their behalf.

tridil2000, MSN, RN · Jul 22, 2006

Yep it is the family's choice. Full code or no code those are the choices, end of story.

agreed. and whomever is offering choices from the acls algorhythms should be reported to bioethics.

tridil2000, MSN, RN · Jul 22, 2006

What fun!!:smiley_ab
The AMA doesn't agree. They support something called Advance Directives and Patient Rights for Self Determination.
Don't have the web address for you, sorry....but go to the AMA webpage...Ethical Decision Making...it discusses the need to respect patient's decision making in regards to life sustaining or life saving measures they wish to have pursued on their behalf.

that was passed in 91 and the ana supports it as well. every hospital should have the pt's rights posted.

people have the rights to pain relief and iv fluid. however, they can refuse feeding tubes etc.

i am specifically concerned with a cardiac/resp arrest. if the wife of a man who was in an mvc states "well, i don't want him alive on machines" that IS completely different than resuscitating him. for example, let's say this 40 year old man is battling lung cancer. he and his wife have made it clear he does not want to live on a vent if it comes to that. so, 4 months after his chemo etc is done, he gets in an awful mvc. the medics intubate him in the field. he has head trauma and the er and icu keep him sedated for 2 days to prevent ^ icp and seizures. the dr should explain this to the wife bc now we want to keep him on the vent to heal, not to sustain him indefinitely. 3 days after the accident he is weaned successfully and has an overall good outcome.

should the medic NOT have intubated him in the field?

each situation is different and most reasonable folks, when educated say, "i don't want to live on a machine." and that is different than "do NOT resuscitate (or at least try to save) me."

again, bc i teach acls and have been to the new updated instructor course, this is a sore spot for me. call in your bioethics team on cases where you think the pt or family need more info, support or education. as staff, we are so busy to really get involved at that level, and the dr is always in a state of "CYA."

catlady, BSN, RN · Jul 22, 2006

I think some of the confusion is over what actually constitutes a "code." Is it only actual pulselessness and absence of respirations? Does it include a thready pulse and profound hypotension? Is it severe respiratory distress with bradycardia? Is it a lethal arrhythmia that hasn't clinically gone lethal yet?

Oftentimes the "code status" is treated long before the patient presents with no pulse and no respirations, and that may be what the "limited resuscitation" means. It's rare that someone is awake and talking to you and doing the happy dance, and out on the ground the next. Usually they start to have intermittent things go wrong on the way out the door, and it's up to you to figure out what is really happening and whether they meet the criteria outlined in their advanced directives. Is this event what they really meant when they said they didn't want heroic measures? There may be patients for whom you see the lights going out and you do nothing, because they have a terminal diagnosis and are a "full DNR." Others may be on their way out, and you will give the fluids and the meds because that's what they requested, but when those don't work, nature is allowed to take its course. Or you're going to do the CPR, and if you get them back by doing compressions and ambu-BVM, fine, but if they need intubation, that's not what they wanted, so you stop. Some people actually will respond to intermediate interventions, which might lead you to think this probably wasn't their day to die anyway. A little old lady might be a DNR because she's been one for 20 years at the nursing home, but maybe all she needs today is a bag of fluid because she's dehydrated from the heat or the hip replacement she just had. Are we going to let her go just like that? Are we not going to treat the patient who goes into V-tach solely because they had trouble swallowing their K-tabs at home, kept taking their Lasix, and now their K+ is 2.0?

What's morally wrong is the "slow code" where the medical team has decided to circumvent the wishes of the patient/family by not responding as directed.

jmgrn65, RN · Jul 22, 2006

we are to ask all of our patients about advance directives, you can't partially code someone, we have full code, dnr cca= where you do everything up to person codes, then dnr cc=only comfort measures. you can't only do compressions and intubate patients and families need to be educated what thier options are you can't do partial no more than you can do a slow code.

caroladybelle, BSN, RN · Jul 22, 2006

It varies greatly from place to place.

In Orlando, DNR or DNI, you also are designated as FAT (full active treatment - everything short of compressions and intubation) or CM (comfort measures only - no pressors, etc.)

In Philly at UPenn, they actually had a 4 level tier of rescusitation.

caroladybelle, BSN, RN · Jul 22, 2006

Actually that is not correct.

In parts of the USA, pressors and some cardiac meds are considered "resuscitation" drugs. As to whether the DNR patient does or does not want them used, is a matter of issue. Some DNR patients merely do not want the dramatic resuscitation if only they are found collapsed and pulseless; However, they may want use of pressors, if their blood pressure is merely unstable and may be corrected by the use of pressors.

tvccrn, ASN, RN · Jul 22, 2006

agreed. and whomever is offering choices from the acls algorhythms should be reported to bioethics.

You keep harping on reporting to bioethics...well we have brought this before them and they have said.......

It is what the patient says it is. That is their wishes and we abide by them, when backed up by the family.

We have a big problem with the family overturing a POHC or a living will. The one thing they can do to render a DNR bracelet null and void is simply to cut it off the patient.

I have a big problem with people who don't respect a patient wishes. If you think you know better than the patient you should apply for the job of the almighty higher power so you can be the one to make those decisions.

Having an agency or government entity decide what is a legal code smacks of controlling a patient's life. If you are going to tell them what they can and can't have done to them as they pass on then what's to stop you from telling them they HAVE to have that chemo or they HAVE to have the surgery that will ensure that hey continue to live for as long as they want you to.

When you get into the realm then you cease to become a provider and start to become a dictator.