"Slow" codes

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I've been an RN for a little over a year now, all that time in a combined CCU/M/S/N ICU. In that time there have been a couple of patients who have been "slow coded" and I was wondering what someone else's experience has been with them. My PA wife is pretty appalled by it and I must confess to some discomfort.

Both patients where I've been in the room have been long term ICU patients (6 weeks +) in multi organ failure, vented, mulitiple pressor support, dialysis, etc. with families in complete denial. Yesterday's patient was in PEA and was on the way out when the director of the unit came in and started pushing epi and yelling for someone to start compressions. After the third dose he got a rhythm back. This guy has been unresponsive for a month and it was a blessing that he was finally dying. Now that he's back the family is faced with the prospect of withdrawing life support on him, which is a whole different story from an unsuccessful code situation.

My question is this: is it ethical to allow nature to take its course when you know the person deserves to be at peace? Or do we have an obligation to make every conceivable effort before the code is called, or worse, we get the patient back like we did yesterday? Any feedback, positive or negative, is welcome. I'd _really_ like to know what you guys think.

Specializes in critical care.

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.

SO true ,so true!!!

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Specializes in Hospice, Med Surg, Long Term.

There are some very good points here. We need to have alot of community education programs in place at all times regarding advanced directives and disease processes. We also need to provide the communuty with the questions to ask that would drag HONEST answers from the MD's. And they need to integrate into this, how UNETHICAL it is to to not honor the patient's wishes when he/she is no longer able to speak for themselves, (after all that is the whole purpose of having advanced directives). We need to point out how selfish it is to honor OUR wishes against the wishes of the patient.

There will always be those who are not willing to do what is ethical, and then there are those who for religious beliefs who will never give up, but if we had community education in place, we would have some back up and we would need to be consistent with those teachings to help make our jobs less tedious when it comes to these issues. But the bottom line is----WE would feel better knowing we did what we could, and can sleep better because of it.

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The situations that you all describe are happening in my workplace as well--and i find it very difficult to nurse such patients feeling i am doingmore harm and creating ill health than good--i agree these situations are very costly to the health care system and cruel in many situations--i feel that some physicians feel quality of life simply means having a heart beat--I have spoken with colleagues who are british trained nurses and have been told that these things would not happen in the U.K.-----------does anyone have any experience of how end of life decision making happens in intensive care in other places besides the U.S. and Canada?

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Specializes in Trauma ICU,ER,ACLS/BLS instructor.

In situations where staff and doc's agree that everything has been done yet the family still resists a cmo status, I have had the family come into the room and see the process of the code. It is not uncommon to have family present in these situations and usually when they see what you have to do,they ask u to stop. If not. Ya do what u have to do. According to the AHA, after the ACLS algorhythms have been carried out,without success,it is prudent to call the code, even if not everyone agrees.( the only good thing my ex husband left me besides my boys,are my inicials,CMO!!):lol2:

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Specializes in ER, Family Practice, Free Clinics.

I had the talk with my boyfriend the other day- told him "If you want everything done in a hopeless situation, you better put it in writing." I'd need that piece of paper in front of me telling me that he WANTED to be tortured in that way- even then I don't think I could let it go on for very long. I just think that a lot of these people who cry "sanctity of life! do everything you can to save them!" just don't know what that entails... or winds up looking like. I'm rewriting my living will if we ever get married- it will be very specific= if I'm never reasonably expected to wipe my own ass again, send me on home to Jesus. I forgive you, now just pull the plug already! I'm not as afraid of dying as I am of living in that condition.

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Specializes in ER/SICU/Med-Surg/Ortho/Trauma/Flight.

I had one that came to mind, I once had this 78 y/o female, in heart failure, cardiogenic shock, AMI, you name it she had it, well we had this premodonna cardiac punk of a surgeon, anyways he proceeds to tell the husband he can do a bypass on her and shell return to normal, well wouldnt you know, she coded 6 times, never came off the vent, stayed in our ICU for months, eventually had to be tranched because her lips and mouth where practically rotting away, she had to have an arm and a leg amputated, and when she finally did die the poor husband ended up with an $800,000.00 bill. Poor guy we all felt so bad for him because of this doc, he shouldve been shot.

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Specializes in Critical Care.
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"

I do/did that too. I took all of the experience and tried to help my dad when he was sick and then dying. I was hoping to let him make the decisions for himself, and he did. But he asked for my experience with different situations before he made his decision. Hopefully each of us is helping our families to not be the family that tortures their loved one. Just imagine where that person would have been if they had not come into the hospital? They would be DEAD already.

As for the slow codes, been in far too many to count, far to graphic to recall, and far too disturbing to post here. One involved a child giving mouth to trach resuscitation on an actively resistive/infective parent. It is no fun being involved, so run for your life if someone asks for your help. Not to be rude of course.

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Another aspect... suppose an attending made a "wrong" call, and "allowed" a "clearly terminal" patient to pass away, possibly in good faith that everyone in the family had been in agreement... and some previously undetected member of the family popped up and successfully sued for - whatever it is they could sue for. And won. How many times do you think that would have to happen before that attending would decide never to let that happen to her/him again? And do you think she/he would tell the nursing staff why she/he'd made that decision? Doubtful.

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I totally agree with your opinion on the baby boomer generation. As we see those before us dying, we are afraid to face the inevitable in a wholistic way. However I think there will be changes within the next deacde as the boomers age, and the shortage of nurses increases. We won't be seeing as many patients lingering with multiple organ dysfunctions,trached to the vent,etc. For one thing, our government won't be paying for it. We have no one to blame but ourselves, we invented the technology and now we have to control it in an ethical and humane way.

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Specializes in Trauma ICU, Surgical ICU, Medical ICU.

I am on a unit that usually does slow codes on almost EVERYONE!! I can certainly feel your pain. There are many patients that we have that we are almost happy for them when they finally pass. In many cases, doctors will tell the family this and that, kind of beating around the bush instead of telling them that their family member is going to die. Some docs are too scared to just say enough is enough! In many cases the explination of all the meds and how theyre NOT working is left up to us as nurses. Keeping a heart beating is not keeping someone living, IMO. All I can say is TALK to family about what YOU want done if you are in that situation. At least they know your wishes and will (hopefully) abide by them. Just my :twocents:

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