slow code?

[pbmnms2]

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.

[Bubbles]

I agree with all posters. You did the right thing! The supervisor was not at all helpful or supportive to you. You were wise to get the other nurse's opinion and together you called for assistance.

Now the ideal thing would be if this family were helped to accept their loved ones condition. But even when patients are admitted to hospice some families have trouble accepting that the end is coming.

It feels like torture to keep doing aggressive measures to patients who have little hope of recovery or quality of life. And that is something we nurses in the acute situation see all too often.

[canoehead, BSN, RN]

To the OP- the supervisor was wrong to have made you feel bad for calling for treatment. You are the one that has to live with the consequences, not her.

I've had maybe one patient every 5 years that might be a candidate for a slow code. Usually at that point the are monitered and medicated to the nines, and there is no way a competent and attentive nurse wouldn't notice a worsening condition. I'm not willing to be incompetent/inattentive, so the doc gets called and the patient gets treated.

Very rarely you'll find a patient contracted and ill, not taking po, been that way for months, and not on a moniter. In theory I can see "letting them sleep" through a set of vital signs. Or not noticing an irregular breathing pattern. But they'd have to be ready to die in the next hour or so, because bringing another nurse into the situation puts both of you in a bad situation. I imagine most nurses would want to know the patient/family well. If they have family that visits I'd want to be able to call and let them say goodbye.

So yeah, I can imagine a patient that I would allow to die without a DNR, but it's never happened. It would have to be no family, no moniters, no verbalizations, constant pain, no hope of recovery that I'd had as a patient over a period of weeks. And they'd have to be dying within hours. Probably even then I'd come up with something to let myself off the hook, because I can be a coward. Don't like to make life and death decisions for someone else (even though docs do it and families do).

I did once have a woman with written DNR/no intubation wishes, and the doc wanted to tube her because the one family member didn't want to make the big decision on his own. to my mind she had already made the decision. I refused to help intubate- that was my big rebellion.

[ZippyGBR, BSN, RN]

being rightpondian and not knowing the exact legalities where you are

does someone have a power of attorney for the patient who is able to 'force' the not getting a DNAR order ? or is it just that the Senior Doctor responsible for the patient hasn't got the cojones to make a DNAR anyway on the basis of futility..

lay people seem to have 2 significant misapprehensions surrounding DNARs

1.CPR is susccessful

2. that a DNAR indicates the cessation of active treatment and a death sentence ... a DNAR is about CPR - the rest of the care plan should stay as it , unless there are good reasons to consider death is imminent and that palliative care rather than aiming for 'cure' is the most clinically appropriate course of action.

[kcochrane]

I did once have a woman with written DNR/no intubation wishes, and the doc wanted to tube her because the one family member didn't want to make the big decision on his own. to my mind she had already made the decision. I refused to help intubate- that was my big rebellion.

Unfortunately even if you make all arrangements yourself on what you want...your family or health proxy can change that. We had a 91 year old man with a trach, g-tube, parkinson's, contractures, etc., who was in constant pain and could not talk. He had everything drawn out with a lawyer on what he wanted and did not want - which was none of the above. His daughter was proxy, but let her brother decide to make him a full code. He got ill one night and was sent to the hospital, coded 5 times and was brought back. Someone finally talked realistically to the family and they made him a DNR/DNI. He came back to our facility and died a few hours later. His face said it all, I finally saw peace on it.

[nitenite]

I'd never slow code anyone no matter how much I'd want to.

But I think it's cruel to keep a 101 year old man with advanced Alzheimer's alive on a vent and all the trimmings in ICU only to have him finally and irreversibly code in front of his family on Christmas day. (Yes, we did everything and we worked so hard that his ribs and sternum just disintegrated.) Especially since the family was wailing and throwing themselves on the body after the code failed. They were NOT prepared at all.

I can't help thinking they could have been saved this miserable Christmas memory if they'd just put the poor man in Hospice.