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 am with the other responders: what you CAN do is try to educate the family about this unfortunate man's quality of life and just exactly what CPR and code teams DO (like breaking ribs) to a person.
Unless and until the person is a DNR (even though you KNOW it is prolonging the inevitable), he is a FULL CODE. You have got to follow the current orders, despite that other nurse's opinion to the contrary. Let HER try a "slow code" when she's the man's nurse:devil:
Specializes in Med/Surge, Psych, LTC, Home Health.
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.
THAT'S a messed up situation right there that I would NEVER want to be in. Wow, I wouldn't want to be there when this man stops breathing and no one seems to know or agree if he is to be coded or not!!!!! The family needs to come to an agreement on this, otherwise in my opinion, the man should still be a full code!
Specializes in Medsurg/ICU, Mental Health, Home Health.
I am with the other responders: what you CAN do is try to educate the family about this unfortunate man's quality of life and just exactly what CPR and code teams DO (like breaking ribs) to a person.
I agree.
I think we've all been there. I was in the same situation a few months back, and I ended up actually breaking the woman's ribs. She looked terrible after the code, covered in blood and feces, but we got her back because I had already called an RRT a few hours prior and all of us in the room were ready for her to go into arrest, so CPR was initiated immediately.
Her husband (the one who would not make her a DNR and actually had consented for her to have surgery later that morning ) came in, saw what had been done to her to save her life, and told me he was going to talk to the intensivist to "change the plan." It took that to change his mind! Later that weekend, the entire family gathered in the ICU and she was placed on a morphine drip and terminally weaned from the vent. Had we, during the RRT, initiated a "slow code," the family would not have been with her when she passed and the husband would have had a completely different reaction when arriving to the hospital.
I agree with everyone else -- no such thing as a "slow code," at least where my soon-to-be license is concerned.
I also wonder why families aren't automatically made aware of the code process, when they insist their loved one be made a full code. I've never seen any nurse explain this during my time as a student or during my externship. They just shrug their shoulders and go with it. I know when my mom was dying (before I went to nursing school), I had no idea and just thought that full code meant I was doing everything possible and that she could recover. It took a kind and brutally honest ICU nurse to tell me (it was all over the phone) exactly what the codes were doing to her before I agreed to DNR. I had no idea.
One thought: sad to say, it could be that the family isn't as attached to Dad as they are to Dad's check that probably comes in every month, and that's why they want everything done. Just my .
Specializes in Medsurg/ICU, Mental Health, Home Health.
I also wonder why families aren't automatically made aware of the code process, when they insist their loved one be made a full code. I've never seen any nurse explain this during my time as a student or during my externship. They just shrug their shoulders and go with it. I know when my mom was dying (before I went to nursing school), I had no idea and just thought that full code meant I was doing everything possible and that she could recover.
I've done it myself. I work midnights, so I don't have as much of an opportunity to talk to families about this, but I've done it. No need to be a grim reaper about it, but sadly this is something physicians are hesitant to do, I think.
I completely agree with the previous post and would like to add, that if something feels wrong in the pitt of your stomach, you should go with it. When I was a new nurse there were many times that I saw things I didn't "feel" were right and I spoke my mind. I felt good at the end of the day that I did the right thing by being my patient's advocate and protecting them and their families wishes when others wanted to do what was easy. Kudos to you.:)
i just cannot imagine what our society would turn into, if we acted on OUR wishes for another human being.
it is scary and dangerous, knowing there are med'l professionals, that do indeed, carry out the slow codes...
more often than we care to admit to.
while i too, wish that God would just take these suffering souls, i am extremely grateful that most of us are honorable folks that can separate our morals, from that of the law.
I am a rapid response nurse. I would have wanted you to call me for a patient like that because the code status is still "full." To ignore a change in VS/condition like that because someone thinks he should not be a full code is unethical and will get you in legal trouble, as the other posters have already pointed out.
I have a "top 10" list of my frequent fliers that I get a rapid response calls on during their hospitalizations. (hmm, make that top 20!) Anyways, these poor souls with every co-morbidity in the book, have decubs, infections, been in an out of ICU, some chronic trach---they have these family members that will insist on everything being done. It is heartbreaking to keep seeing these people die a slow death, us bringing them back from the edge only to see them come back in a few months in the same shape. One man told me "I wish you'd let me go." However, the minute we "slow code" one of these people and they die (or worse have anoxic brain post-code) I wouldn't be surprised if some family member calls a lawyer. So in the meantime we keep transferring them back to ICU, giving them a vent/pressors/dialysis for another go-round.
I've been a nurse for a long time. When I worked in the hospital long ago at the beginning of my career, I heard that term used once. It is a very old term. I am betting your supervisor has been a nurse for many years. It is not up to us to make decisions like we were God. The story went like this, we had a lady with advanced COPD. She would come into the hospital in respiratory distress, be intubated and put on a vent, and admitted to ICU. After a few weeks she would be taken off the vent , her sats would improve, after many respiratory tx's, then go onto the regular floor for a week or so, then be discharged home. Then in a few weeks she'd be back and the whole thing would repeat itself. I am trying to remember what her circumstances were, re: family or what and their wishes,might even have been one of the old docs was her physican, but she often told the ICU staff she was tired of all this. Then one time she had been extubated, and was slowly getting somewhat better. But that night she died. The story was that they went in 3 times with her dinner tray before calling a code, she passed away that night. I've never forgotten. I was a new nurse and questioned why this was done, I never got a straight answer, only told it was a "slow code".
Do not beat yourself up because you did nothing wrong. In fact, you did everything right.
I have heard the term "slow code" being thrown around forever. Most of the time I think it is just wishful thinking on the part of the staff. I mean, they wish they could respond slowly to ease the pts pain and let them go. But it is not our decision to make (thankfully). I have been fortunate to never ever see anyone try and provide a slow code, and I have never even heard a story about a slow code actually being performed. It doesn't exist, morally, legally or ethically.
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liebling5, MSN, RN
1 Article; 143 Posts
I am with the other responders: what you CAN do is try to educate the family about this unfortunate man's quality of life and just exactly what CPR and code teams DO (like breaking ribs) to a person.
Unless and until the person is a DNR (even though you KNOW it is prolonging the inevitable), he is a FULL CODE. You have got to follow the current orders, despite that other nurse's opinion to the contrary. Let HER try a "slow code" when she's the man's nurse:devil: