"Thumping" out the door....?

TheCommuter, BSN, RN · Jun 20, 2011

A lady that runs the Hospice in my county came and talked to our clinical group and she also stated they have full codes. She said although usually the person is DNR it's a myth that they HAVE to be, that there are always exceptions.

This is very true.

However, one benefit of receiving hospice services is that the patient has the chance to experience a peaceful, dignified death without being pounded or poked. If the hospice patient is a full code, you can forget about ever having a peaceful death.

akulahawkRN, ADN, RN, EMT-P · Jun 20, 2011

This is very true.
However, one benefit of receiving hospice services is that the patient has the chance to experience a peaceful, dignified death without being pounded or poked. If the hospice patient is a full code, you can forget about ever having a peaceful death.

I wouldn't be at all surprised if the patient or the person with the DPAHC sometimes does not quite understand that Hospice patients that are a No Code in the Hospital, those orders often do not follow the patient home... thus reverting to a Full Code with all the flogging, poking, prodding, intubating, and transporting that comes with it... when what was desired was none of that.

My reference to someone panicking was in reference to a DNR patient's family member that doesn't want to let go... Hospice Nurses know better, but when the patient is Full Code... they have to do what they must too.

caroladybelle, BSN, RN · Jun 20, 2011

Because you were HOSPICE. Most hospice facilities/programs require DNRs to be signed before accepting admission.

Unfortunately, that is not permitted as a requirement in some states, ironic though it seems. In both FL, and GA, a hospice pt is not required to be a DNR.

The exact issue seems to be that you cannot discriminate in hospice admission, based on DNR/nonDNR status.

AnnieOaklyRN, BSN, RN, EMT-P · Jun 23, 2011

EMS cannot decide when to pronounce a patient.....that will be up to the doctor at the hospital. I once rode with the ambulance and we pulled a very dead body from a pool......the body went on the thumper until we got to the hospital.

Better do some research! Yes we can, although we are not prnouncing them dead we can and do decide when someone is not workable and can make the desicion not to even start any resus efforts ( this is the case in most states if not all) or in my state we can also work them if they are fresh for 15 minutes and either continue resus efforts or make the desicion to stop and that is without med control!

AHA guidelines suggest that people who do not regain ROSC within 15 minutes are not going to.... Thus continued efforts are likely to be futile; however I personally base my desicion on ENd Tidal CO2 and rhythm.

EMS is a lot more advanced these days than most nurses realize!

Happy

AnnieOaklyRN, BSN, RN, EMT-P · Jun 23, 2011

Flat line? That means no shock.
CPR is continued to maintain circulation until they get to an ER with more resources to attempt resuscitation.

You are incorrect my friend! We, as EMS providers have the same resources and ER is going to have jna code situation! The only exceprion to this is cracking a chest in traumatic arrest, but lets face it traumatic out of hospital arrest means your dead anyway!

We have the same drugs, same electricity, and we go by ACLS guidelines just like the ER. There are no " more resources" that the patient will get in the ER. As a matter of fact in my state we are allowed to not work the patient at all if they have a prolonged downtime or are in traumatic arrest and we are also allowed to stop working patients after 15 minutes if they do not have ROSC and leave them on the scene. This is an AHA guideline and I can tell you that 100% of the time if there is no return of ROSC on arrival to the ER they are not going to use the more resources you think they have, they are gonna cover them with a sheet and call it, thus transporting these patients is a waste of time and money and I find that families actually appreciate our ability to call it at the house!

So do some reasearch EMS is a lot morw advanced tnen you think, we have End tidal co2 now and most ERs dont even have that to make my point!

Happy

nola1202 · Jun 25, 2011

EMS cannot decide when to pronounce a patient.....that will be up to the doctor at the hospital. I once rode with the ambulance and we pulled a very dead body from a pool......the body went on the thumper until we got to the hospital.

iiiiiiiccccccckkkkk! (ick) never had the displeasure of seein this!

steelydanfan · Jun 25, 2011

Ok so Im in SNF. We had a code today. By the time we get to the room with the crash cart its obvious we're too late to do any good but because she was a full code we jumped in (or on) full steam ahead until EMS can get there.EMS rolls in, hooks up the monitor....flat line. They shock...nothing. They do all they could possibly do but like I said, it was obvious we were too late. So then they hook up this thing they called the "Thumper" that performed mechanical compressions and was basically hands-free CPR. They prepared her for transport with this attached and loaded her into the truck. My question is, why did they continue these compressions when it was clear that she was gone? My first thought was that perhaps it was to keep the circulation going in case she was a doner. But if that were the case wouldnt they be bagging her also? and are the elderly with multiple chronic diagnosis even eligible to donate? It was just disturbing watching this little ole lady convulse as shes being pounded on leaving our facility instead being treated gently in her passing.

Because someone in your facility did NOT do the right thing and pressed and pressed and PRESSED the family for a DNR order.

So this poor lady wound up the victim of her families inability to decide on a rationale course of action, abetted by the nursing homes wish to 'Not offend the family".

Who is the winner here? Certainly not your patient.

caroladybelle, BSN, RN · Jun 25, 2011

Because someone in your facility did NOT do the right thing and pressed and pressed and PRESSED the family for a DNR order.
So this poor lady wound up the victim of her families inability to decide on a rationale course of action, abetted by the nursing homes wish to 'Not offend the family".
Who is the winner here? Certainly not your patient.

It may not have be the family's decision.

There are people in SNFs, in many cases, that are alert, oriented- thus it is their decision.

And it is not a matter of pressing the family into this decision. One can often present ALL the data, they can be very well educated and knowledgable, but due to religious/cultural/psychosocial issues, unable to say/sign DNR orders. And indeed, this may be the pts competently made choice.

We do not necessarily believe the same way, and we may find it useless. But it may indeed be what they want.

hiddencatRN, BSN, RN · Jun 25, 2011

Because someone in your facility did NOT do the right thing and pressed and pressed and PRESSED the family for a DNR order.
So this poor lady wound up the victim of her families inability to decide on a rationale course of action, abetted by the nursing homes wish to 'Not offend the family".
Who is the winner here? Certainly not your patient.

I wonder if people really care about what is happening to their body after they die. They are, well, *dead* after all, right? I don't really see a win/lose option for the patient here...

Persephone001 · Jun 27, 2011

I ran as an EMT for awhile and once CPR is started, as far as EMS is concerned, they cannot legally stop CPR until they are told to by an MD. Except in a case where the patient is very obviously dead. Once they start CPR they also cannot stop or pass the patient on to someone else for unless they are relieved by someone of a a higher title than they are.

akulahawkRN, ADN, RN, EMT-P · Jun 27, 2011

I ran as an EMT for awhile and once CPR is started, as far as EMS is concerned, they cannot legally stop CPR until they are told to by an MD. Except in a case where the patient is very obviously dead. Once they start CPR they also cannot stop or pass the patient on to someone else for unless they are relieved by someone of a a higher title than they are.

This is true for EMT level care. Advanced level providers usually have a some kind of protocol that essentially states to either transport early or follow the appropriate cardiac protocol for 15 to 20 minutes and then cease efforts if no ROSC at that point. Where I live, the EMS system specifies that efforts can cease if the initial rhythm is asystole and after 3 mg Epi and 3 mg Atropine OR 20 minutes has passed since efforts began, and the patient remains in asystole. VF/Pulseless VT/PEA as the the initial presentation results in a transport. Another county that I'm familiar with is similar, but adds that PEA with a rate

Is an MD telling them when to stop? In a way, yes, but not in a direct manner. A base order may also be obtained to cease efforts, but this is not normally explicitly stated in the guidelines/protocols for EMS personnel. Such a thing would be covered under the need to obtain an order for a situation that is outside the protocols. Also, under certain circumstances, CPR can be stopped because the providers are all too exhausted to continue. This isn't normally a problem in urban/suburban areas.

steelydanfan · Jun 29, 2011

It may not have be the family's decision.
There are people in SNFs, in many cases, that are alert, oriented- thus it is their decision.
And it is not a matter of pressing the family into this decision. One can often present ALL the data, they can be very well educated and knowledgable, but due to religious/cultural/psychosocial issues, unable to say/sign DNR orders. And indeed, this may be the pts competently made choice.
We do not necessarily believe the same way, and we may find it useless. But it may indeed be what they want.

You may not have seen the recent CBS news segment on this very subject. We all fall back on the excuses: Well, they objected to it for religious/cultural/ psychosocial issues; but the truth actually is that 9 out of 10 of those pts/families had NOT been approached properly, and WHEN THEY WERE, they declined to be coded. Some terminal cancer pt's had a belief that CPR would "save" them. We are NOT doing the right thing as far as education for our pt.s.