"Slow" codes

deeDawntee, RN · Aug 30, 2007

I think we are ethically required to do everything we can if the patient is a full code. In the cases of these long term ICU patients, I think the Docs have not done a good job being in communication with the family about the pt's prognosis. I put the responsibility squarely on the Doctor/patient(family) relationship. As a nurse, I am rarely, running a code, if I am it is only for a very short time until a Physician shows up on the scene...at that point there is not much I can do to influence the way the code is run. Personally, I have not seen a slow code, but I would have to imagine that it would really upset me. Not because a very sick patient finally was allowed to die, but because they were kept alive far beyond what was reasonable given their medical condition, and to put on a "show" to appease the family would really anger me!! I just hope and pray that I never have to be witness to it. I don't think anyone should.

Long Term Care Columnist / Guide · Aug 30, 2007

Slow codes are unethical, and as much as I might disagree with a decision to resuscitate someone who (IMO) has no quality of life and no chance of any, that's not my decision to make.

I think the only answer to the 'slow code' dilemma is going to involve many years of educating our society about the dying process and when we should, and should NOT, interfere with it. The American public draws its pictures of what happens during a code from TV shows such as "ER" and "House", and of course it expects miracles from us because of all those news stories and documentaries about 22-week preemies and 800-pound men and cancer-ridden housewives who survive to fight another day.

What Americans typically DON'T get is that the mortality rate---eventually---is 100%.......and that sometimes, dead is better. They called pneumonia the 'old man's friend' back in the day for a reason. Death wasn't at the end of life; it was all through it, with mothers who died in childbirth.......babies who didn't make it through their first year........teenagers who got a dog bite or a puncture wound that ended in lockjaw. My grandmother used to say the Grim Reaper was a frequent visitor in her day, and sometimes, she said, you could even feel him breathing down your neck.

But America doesn't want to hear that, doesn't want to deal with death. We Baby Boomers are probably the worst offenders with our refusal to grow old gracefully. Everyone wants to become wise, but few of us want to be old, and NOBODY wants to die. So we have all these scientific miracles at our disposal, and by God, we want them all used on our loved ones so we can (sometimes selfishly) hang onto them as long as we can. You see, when our parents go, it means we're next.........and in our quest to remain forever 17, we refuse to face our own mortality even when it's staring right back at us in the bathroom mirror.

Yet all I hear from members of my own generation is "I don't want to be in a nursing home, I don't want to be bedridden and having to have someone wipe my butt and feed me---if I get to be like that, I'd rather not be here". So it's going to be up to healthcare professionals to help gently turn around this trend of "do everything at all cost" and return the process of dying to its rightful place in the circle of life. We can't keep looking the other way as our elders suffer, often for years on end, in a twilight world with ruined bodies and tattered minds. After all, it's not what most of us want for ourselves........and as the Golden Rule says, "do unto others as you would have done unto you".

txdude35 · Aug 30, 2007

Thanks for your input. I agree that the docs many times aren't as straightforward as they could be and and have witnessed occasions where the doctor has given the family hope where, in reality, there was none.

In the case I'm referring to, all the docs on the case have been consistent in telling the family that the prognosis was very poor since day one. After the code the primary and the intensivist met with the family and laid out the entire picture in a way that left no question that it was over. After listening politely the wife said "Ok, but when is he going to get better, because I'm going to keep him alive as long as I can. I'm not disconnecting ANYTHING." In the first one I saw there was telemetry nurse in the family who kept loudly questioning the nephrologist and the nurses on the case why we weren't treating his uncle's renal failure with Mucomyst (the guy had a creatinine of 8 at one point, never less than 4, on daily dialysis and the CRRT). He, of all people, should have known better and despite all the promptings he got to research multi system failure never acknowledged that his uncle was cooked.

I'm trying to wrap my head around this dilemma, and have been since the first one. Where does my primary responsibility lie? As a patient advocate, it is my responsibility to protect the patient from situations within the healthcare system but how is it unethical to protect them against the family?

At what point do I do what's right for the patient and put a misguided family's wishes second? How do I go home knowing that I did the right thing, whether it be rescucitating a patient whose EEG is basically a flat line because the family doesn't get it or allowing that person to die in peace?

ElizabethJRN · Aug 31, 2007

mjlrn97...very well said!!

I have never seen a slow code, but I have seen a patient code 7, yes SEVEN times during his stay in our hospital. He was one of those patients where we were saying ~ PLEASE let him die! Yet the family said NO. Finally during his last code I believe the docs just said that is ENOUGH and called it!

Ethically we must do what is ordered based on the patients/primary decision-makers' wishes, no matter our opinion. A lot of times the doctors do their best to persuade the family, saying 'there is nothing more we can do'. Believe me, most of the time we do not agree with what is ordered, but it is what we must do.

Burnt2 · Aug 31, 2007

I've seen slow codes. I never feel good about them. I feel it disrespects the patients humanity, and the families wishes.

There was one exception that I was involved in a few years ago where I thought that nonmaleficence/beneficience was completely raped, and it was unethical and immoral to full code the patient. So the patient was "slow coded".

In the end though its not up to us as nurses to decide whether a pt has the right to a full code. That is up to the POA/family, courts, and potentially the doctor.

Its a very complex issue.

montieICURN · Aug 31, 2007

Some docs could pump life into a rock. They take pride in it. I quietly proclaim to them, "You know, by coding this patient for 45 minutes, you are only showing your age."

AHA guidelines today elude that if you code a patient for more than 10 minutes with no response, you aren't doing them any favors.

It's the doc's call. You have to have a doc that is willing to say, "She's gone. There is nothing else that we can do." Most of the docs are afraid of being sued. We code people who have a living will because the family wants everything. The docs say the dead can't sue them.

I had a patient a few weeks ago that presented with shock, was ESRD on hemo M-W-F, now presented with uncontrolled metabolic acidosis and MSOF. High white count, looked pregnant, ileus for 2 weeks. You guessed it, dead gut. This is without mentioning his 10%LVEF, COPD, and rotting legs due to PVD. He needed surgery. The surgeon and the anesthesiologist said, "NO WAY." Well when the attending cardio guy is asked if he wants to talk to the fam, he says, "ALL YOU PEOPLE WANT TO DO IS KILL PEOPLE." Due to the MD's denial, and the false hope it gave the family, we did code this patient, 2 days later. You can guess the outcome. Sure feels unethical to me.

I think the "slow code" term is just a way of dealing with the fact that we are all participating in a code that is unethical, and we know it. We all say we're going to do CPR with one finger if they code. Not really, it's just a defense mechanism. One doc tubed a lady and said, "We're going to hell for this." Some docs just don't have "the talk" in them to get a code status changed.

We have a few frequent flyers that are rotting on vents, bedsores, clinitrons, tube feedings, dialysis, no family visits. VERY SAD. Once a month or so they present with septic shock. We pump them full of fluids and pressors, get the pressure back, change the lines and the antibiotics, and send them back. They are all full codes. After all, they live that way in a SNF. They can return to that quality of life, so why not save them? :madface: They wonder why healthcare costs are through the roof? Docs need to get some training on "the talk" in school, (some just need to grow some balls).

txdude35 · Aug 31, 2007

Roger that on the docs, montie. I still can't believe how many people with an advance directive we code because one person in the family doesn't agree with it and how many docs tell the family there's hope when the patient is rotting away in the bed. I love what I do, but some mornings I go home feeling dirty because of the torture we put some of these poor people through.

RNperdiem, RN · Sep 2, 2007

I have never seen a slow code. The patients I work with tend to be trauma patients, often with a good prognosis.

Nurses do tend to get caught in the middle between the docs and the families, and there isn't nearly enough communication between the groups. Unless families catch the doctors on rounds, little progress is communicated to them. The nurses say what they will; it is the doctors who they need to talk to.

Luckily a code is a way of trying to revive the dead. Most of the dead stay dead.

gizelda196 · Sep 5, 2007

Some docs could pump life into a rock. They take pride in it. I quietly proclaim to them, "You know, by coding this patient for 45 minutes, you are only showing your age."
AHA guidelines today elude that if you code a patient for more than 10 minutes with no response, you aren't doing them any favors.
It's the doc's call. You have to have a doc that is willing to say, "She's gone. There is nothing else that we can do." Most of the docs are afraid of being sued. We code people who have a living will because the family wants everything. The docs say the dead can't sue them.
I had a patient a few weeks ago that presented with shock, was ESRD on hemo M-W-F, now presented with uncontrolled metabolic acidosis and MSOF. High white count, looked pregnant, ileus for 2 weeks. You guessed it, dead gut. This is without mentioning his 10%LVEF, COPD, and rotting legs due to PVD. He needed surgery. The surgeon and the anesthesiologist said, "NO WAY." Well when the attending cardio guy is asked if he wants to talk to the fam, he says, "ALL YOU PEOPLE WANT TO DO IS KILL PEOPLE." Due to the MD's denial, and the false hope it gave the family, we did code this patient, 2 days later. You can guess the outcome. Sure feels unethical to me.
I think the "slow code" term is just a way of dealing with the fact that we are all participating in a code that is unethical, and we know it. We all say we're going to do CPR with one finger if they code. Not really, it's just a defense mechanism. One doc tubed a lady and said, "We're going to hell for this." Some docs just don't have "the talk" in them to get a code status changed.
We have a few frequent flyers that are rotting on vents, bedsores, clinitrons, tube feedings, dialysis, no family visits. VERY SAD. Once a month or so they present with septic shock. We pump them full of fluids and pressors, get the pressure back, change the lines and the antibiotics, and send them back. They are all full codes. After all, they live that way in a SNF. They can return to that quality of life, so why not save them? They wonder why healthcare costs are through the roof? Docs need to get some training on "the talk" in school, (some just need to grow some balls).

and how many times have you lived though this scenario:

The family asked you questions. you tell them in your experience with dealing with the pt that is "dead in the bed, on a vent, and pressors with body rot"(not in those words) the truth,

and the doc comes in gives them hope because he just can not say the words" futile and dying" and now the family hates you and looks at you like your the reaper. Blah blah blah.

what happen to death with dignity?I know I sound bitter and sarcastic but I see this over and over and over again and I think when will this madness stop? I remember an intern running up to the unit with the worried look about the 98 year old found down and is now intubated in the ed and boy is she sick and going to require a lot of work or we could lose her tonight and I said "What? She was in a natural process of DYING are you people crazy?" and this intern was just so shocked that I said something so "offensive"

My newest pt was admitted with prostate ca withs mets . He needed an "emergent"ERCP with stent placement for palliative measures only to relieve the pain of his compressed Bile duct. He came to the unit because we can do this for him at 3am. Well his INR was almost 5, so guess who didn't get his palliative procedure and now is seriously ill? He came in with his DNR, guess what the family has done since he cant make his decision now. YUP you guessed it, rescinded. How can this be legal? Isn't this unethical? letting him go is his choice coding him is the families. oh ya and guess what no one has been into visit him in 2 shifts and we cant medicate him because "it could kill him" HE IS DYING! I could go on this subject really just gets me made because I feel so helpless. But we as a unit talk about these travesties all the time .How do we turn talk to ideas?and then into action.

Some one else said it we need to educate the public on the dying process and start lobbing TV shows to stop all these "MIRACLES"

I for one will still get DNR tattooed across my chest along with Do not insert tubes on my throat and belly!!!! And I know my entire family is sick to death of me using our family get togethers":as a lets talk about every ones end of life choices" but I will continue to use this time just for that!

And I still say to the family "does anyone know what the patient wanted ?did you ever discuss what to do with your loved one? Please try and remember what your loved one would have wanted while you make your choices.(as the intern/resident quivers in the corner)

montieICURN · Sep 7, 2007

My newest pt was admitted with prostate ca withs mets . He needed an "emergent"ERCP with stent placement for palliative measures only to relieve the pain of his compressed Bile duct.
We had the same scenerio, 94 yo, colon CA with mets was too combative for the ERCP due to demetia. So logically, they tubed him and did it in the OR. No code, on the vent for 4 days. Ya know, they pay us to torture them until they're dead. Whatever you say doctor. They wonder why we are so tough. Ha! They give the orders and go home. Save them all, I say!
I just started a new job. Hopefully I will see less of the hopeless stuff.

Elvish, BSN, DNP, RN, NP · Sep 12, 2007

I had 'the talk' with both my mom & dad recently (they are divorced, so I am legally next of kin for mom, and would be for dad should something happen to my stepmother). They both want everything d/ced if the prognosis is poor. They both want to go on to glory. I am glad to know that, because if either wanted everything done, I don't know how long I could sit and watch them be tortured until they inevitably die. I have watched many people fighting to die while family members, who are guilt-ridden that they didn't spend enough time c said relative while they were well, are fighting to keep them around. It is so sad and so wrong. I have told everybody around me what I want so by golly they better just let me go on home too, if it's at the point where nothing more can be done.

I think too, people confuse "no code" with "no care". You and I know that's not true, but a lot of laypeople don't. With the OP's situation, that may not have been the case, but I have seen it numerous times (though not in the ICU). Good thread.