slow code?

fiveofpeep · Apr 24, 2010

it sucks that we have to preserve these patients long beyond what their bodies could sustain but it's not our job to decide to hold back. You were in the right. You cant just let him die because his quality of life sucks. That's what we have ethics committees for.

PAROPPY, BSN, RN · Apr 24, 2010

You 100% did the right thing. It sucks that we have to keep people alive beyond the time their number is up, but it is not our decision. We do the best we can with what we got. The supervisor was wrong in saying that to you. She can vent all she wants about having to keep that poor guy alive but she should know there is no such thing as a "slow code" and to insinuate that you should have treated the situation as such is terrible. Don't let anyone rock you like that. You did the right thing without a doubt. I myself have transferred many 90+ y/o to the ICU for new onset variable heart block, cva's, etc. (much to the dismay of the ICU nurses). NO DNR = FULL CODE.

vamedic4, EMT-P · Apr 24, 2010

You did the right thing. Regardless of the nursing supervisor's opinion, you are the primary responsible party for this patient. Your charge nurse agreed with your assessment of the situation and you both called the RRT. You did what you felt was in the best interest of the patient because his condition warranted it. You are correct, we can't exactly say "I think I'll take my time on this one," just because it might further the patient down to the end of the road. Well done. And I hope your next week is better than your last.

chenoaspirit, ASN, RN · Apr 24, 2010

I agree with everyone's responses. There is no such thing as a "slow code". Either you code them or you dont. Imagine if you had "slow coded" him and he became worse but lived and his quality of life became worse. You absolutely did the same thing I would have done in that situation. No DNR means Full Code. Always do what you feel is right for the patient and for your conscious and license.

EMSnut45, BSN, RN, EMT-P · Apr 24, 2010

There is no such thing as a "slow code." Slow codes will do nothing but get you into legal trouble. Full code orders mean you do everything. DNR orders mean no code. There isn't a middle ground...

You absolutely made the correct call! In the end, it's your license.

greenfiremajick · Apr 24, 2010

A few nights ago, I was taking care of a 67 yo trainwreck, frequent flyer. Multiple decubs, some with wound vacs, hx of CVA and non verbal, contracted, has a peg. In and out for sepsis with stays in on the floor for weeks. He is a full code. The family has been approached MANY times about making him a DNR but they are totally against it. They want everything done for their father, they come and see him every day. Docs have told them that he will not really not improve...ever. But they are still not ready to "give up on him" (as they think).
Anyway, I have taken care of him a few times this past admission and during this shift he was stable, I did the typical turn, bathe, change dressings and all was tolerated fine, vitals good all night. But at the end of my shift I was giving 6 and 7 am meds to him and I went in and he looked awful so I got his vitals and bp was 70/40 manually and hr in the 150s. So I grabbed my charge nurse first to come take a look because I wanted a quick second opinion before I called a rapid response. She came right in and agreed we had to call a rapid. So I did and he wound up getting transfered to ICU after the doc called the family AGAIN making sure they wanted us to do absolutely everything. Which they did and were a little annoyed they were asked again regarding this.
The problem is the nursing supervisor on that night had a problem with me calling a rapid response on him because she feels he should be a dnr and even though the family doesn't agree we should have really taken our time with him. She suggested I called his attending doc maybe a couple minutes after I passed all my meds that morning, using the term "slow code." Now I am a new nurse (7 months) that had never really crossed my mind before. My heart does break for the poor man who has no quality of life, but I felt like I could not turn my back on what I saw and would be documented (the vitals). I would even feel guilty leaving it for day shift to handle! I felt that the patient needed a higher aquity floor at that time than just a med-surg floor.
I left that day happy that I actually handled only my second rapid response half decently but then confused and upset wondering if I had done the right thing... All the nurses I work with assured me I did the right thing and not to pay attention to her because after all it is MY license and it was the family's wishes. Later in the week the supervisor came to me again and apologized for what she had said before but then went right back again explaining what she would have done and asked why I really felt the need to call a rapid response "on this poor soul." I was just at a loss for word at that point.
I am just so frustrated and still a little confused. I guess I am looking for some input and needed a place to vent.

I agree with what five of peep said " That's what we have ethics committees for." I also think this would be a great response for that nurse and to others when you are asked, or assaulted with their opinions...

Long Term Care Columnist / Guide · Apr 24, 2010

Welcome to my world.

I just sent a 95-year-old gentleman out to the hospital for the fifth time this year. He has severe dementia, a mouthful of rotting teeth, an amputated right forefoot, chronic renal failure, degenerative joint disease, ischemic colitis, you name it......and his POA, who isn't even related to him, just wants us to keep flogging his failing body with more and more meds (which he often refuses to take). She also wants us to keep forcing him to eat and drink when he doesn't want to, and everytime he goes into ARF he gets sent to the hospital for yet another tune-up. The EMTs who came out yesterday looked at me, then at him, and said "Are you serious??!! This guy should've been dead a year ago.....why are we even doing this?" I merely said, "Ask his POA. I'm only doing what I'm told." What else could I have done? It wasn't my decision to make.

If it had been, I could have taken my time to saunter down the hall when the aide told me she couldn't get a BP on the poor fellow; judging by his skin color and his lack of responsiveness to the sternal rub, I knew it would be only a matter of hours (if that long) until the rest of his systems failed and he went home to his Lord. I felt soooooo bad that I couldn't simply give him a little morphine to ease his air hunger and allow him to relax enough to slip away from this pain-filled, confused existence.

But again, it is not given to us nurses to decide when it's time for our patients to die, even though we may believe that death would be a kindness to them and a relief to everyone else involved. Perhaps it's best that way.......that is a terrible responsibility, and those of us who have had to make that decision for a loved one ourselves know that all too well.

DNR status is like being pregnant: either you are, or you aren't. There is no in-between, no way to be "sort of" or "only a little". And there is no 'slow code'---that is unethical and illegal.

kcochrane · Apr 24, 2010

Your supervisor is neither a doctor nor the family. Therefore she/he has no right suggesting anything of that nature. Imagine if you did what they said, someone found out and you ended up in court. Think that supervisor would back you up or if they did that it would matter?

Unfortunately some family members just can't get to a place where they understand that their family member is suffering and will not get better. This leaves us, the nurses, to deliver care that we really know is causing pain and/or prolonging someone's suffering. It is tempting to walk a little slower or wait a bit to call, but as others have stated, it is illegal and immoral.

I ditto - you did the right thing. :)

systoly · Apr 24, 2010

Many moons ago, while still in school, the issue of "slow code" came up. It was wrong then and it still is wrong now. We wouldn't contemplate giving meds late or slowing IV's. Forget about legal consequences for a minute, forget about the tragic consequences of possibly prolonging suffering. A slow code is a fundamental betrayal of trust and without trust I might as well not practice.

JenniferSews · Apr 24, 2010

Your supervisor is neither a doctor nor the family. Therefore she/he has no right suggesting anything of that nature. Imagine if you did what they said, someone found out and you ended up in court. Think that supervisor would back you up or if they did that it would matter?

I almost wonder if you hadn't admitted the pt I sent out this week.

Although the staff for my pt has mentioned "slow code" the truth is none of us would do such a thing. We do not have authority or the moral right to make a decision like that over the family, even if we strongly disagree. I have a defined difference in how I treat my hospice pts and my full core pts. That status is in the back of my mind every time I assess them. Your charge is walking a fine line, knowing you and your license would be the one on the line. Like the PP said it is a fundamental betrayal of trust to not carry out the care that was promised to the pt and family on admission.

medicrn13 · Apr 24, 2010

Had an issue similar to this the other night.

Had a patient come in, 91 years old. The doctor approached his daughter, his HCP, about signing a DNR order for him. The daughter agreed, the paperwork was filled out, but when we went to place a DNR bracelet on him, she freaked out, saying that her other sisters would be upset if they found out she had made him a DNR. She threatened to rescind the DNR if the bracelet was placed, so it wasn't.

When I got report, the evening nurse said to me, "So technically he's a DNR but what they'll do is slow code him and take the family outside and explain that he's DNR."

I looked at her and simply said, "No..." That is a totally uncomfortably, unethical situation that you DO NOT want to be in. At the end of the day, it's your license, and more importantly, your conscience. You did the right thing.