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Discussion

Slow Codes and Extubating a Conscious Pt

During my last clinicals, I found out about Slow Codes...not formally of course, but as a practice on the hospital. Do your hospitals do Slow Codes?

I guess it's ethical, but to me it seems borderline.

The other shocker: extubating a conscious pt. Is this a regular practice? The patient was early twenties with CP. I think she had pneumonia too, at any rate, she was chronically ill. She couldn't talk much (that I could understand) but was able to respond basically. She looked around the room, focused on what the nurses were doing, I guess I'm trying to say, she seemed pretty aware. The nurse said they were going to extubate her, and being a newbie, I said, Oh good! ...thinking I would get to replace the tubing or something. I was confused why she didn't bring any new tubing into the room. She was talking to the pt, saying, 'its ok...it's gonna be alright, sweetie, you're not going to hurt...' that kind of stuff. So I was surprised again when she extubated the pt and over a period of time did not seem too concerned with the pt. The nurse kept taking me into the room and I kept thinking that we were waiting to see her breathe on her own ---I was very confused! At last it hit me that she was going to die. Over the last hour or so, the nurse gave her several mgs of morphine, but as far as I could tell, she was pretty 'awake' thoughout the entire thing. Have you seen this done before? I always thought a pt would NOT be conscious when life support was d/c'd.

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It happens and you have to see the OTHER end to really appreciate how compassionate and caring that nurse was. The other end is a terminal patient who is conscious with a tube down their throat (which is not only painful but causes choking/gagging sensations) while they die. Leaving the tube in might extend life in the very short term but it will not effect the inevitable outcome.

Yes it happens.

  • Author
It happens and you have to see the OTHER end to really appreciate how compassionate and caring that nurse was. The other end is a terminal patient who is conscious with a tube down their throat (which is not only painful but causes choking/gagging sensations) while they die. Leaving the tube in might extend life in the very short term but it will not effect the inevitable outcome.

Yes it happens.

WOW

WOW

When I worked as a resp therapist, I extubated conscious people all the time. We would wean them off the vent and take the tube out. Some times the pt and/or family would make a decision to withdraw life support to let the pt go peacefully and we would do that too. Two very different situations.

To answer the first question, I find "slow codes" to be extremely unethical. It is the decision of the patient or the people acting on behalf of the patient to determine code status. If they maintain that the patient is a full code, then we are to treat the patient as such. It is not our job to determine the final wishes of the patient, that falls to the patient and their family. The patient's wish to remain a full code expresses their desire for us to resuscitate them if needed, whether or not we agree with the decision we still must honor it.

As for the second question, on my unit all of our ventilated patients are trached. As a stepdown we do not take orally intubated patients. When we discontinue ventilator support, we generally deflate the cuff, and place the patient on a trach collar of humidifed air. Morphine/ativan is given for comfort, we generally leave the trach in the trachea.

  • Experts
During my last clinicals, I found out about Slow Codes...not formally of course, but as a practice on the hospital. Do your hospitals do Slow Codes?

I guess it's ethical, but to me it seems borderline.

FYI, "slow codes" are NOT considered ethical practice (although, unfortunately, they do still happen). The practice was being debated and soundly rejected by all the professional organizations back when I was in nursing school 20-some years ago. It is inherently deceitful (leading the patient and/or family to believe that healthcare staff are providing an intervention that they are not really providing), and violates the patient's and/or family's right to be involved in making decisions about treatment/care. If the physicians involved really believe that attempting resuscitation would be futile in a given patient's situation, which is certainly often the case, the ethical thing to do is to discuss that honestly and directly with the patient and/or responsible person(s).

Here is a link to one discussion of the issues involved:

http://www.cumc.columbia.edu/news/review/archives/medrev_v5n2_0002.html

As the article states: ... Despite the widespread practice of slow codes, many physician groups and professional organizations have taken positions against its practice. In 1983, the President's Commission on Ethical Problems spoke out on the subject ...

Other groups also reject the slow code as a therapeutic option. The American College of Physicians' Ethics Manual states: "If DNR orders are not written, it is unethical for physicians and nurses to perform half-hearted resuscitation efforts (so-called 'slow codes')".4 ...

Obviously, you're not going to be able to keep unethical physicians from implementing "slow codes" (and that's not the point of this post; I'm not criticizing you in any way :) ) -- just wanted to clarify about the status of the practice, since you asked about it.

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