Slow Codes

dolldoctor · May 21, 2007

Age does not matter. If pt. requires compressions and fx happens because of compressions, compressions continue.

I've had fx ribs before from a MVA. Lord almighty!!!! OUCH!!!!! I can't even imagine the pain of having compressions done to me at that time!!! And what if the fx ribs puncture the lung? Geezie Peezie!! Seems to me that code would go south in a hurry. :devil:

I'm going to advocate living each minute like it is your last. Always be grateful for the time you have had and then being able to face the end with as much dignity as possible.

Editorial Team / Admin · May 21, 2007

And what if the fx ribs puncture the lung?

You continue compressions if no pulse.

Then, fix the pneumo/hemo-pneumo created with compressions. Common in CPR.

Ouch is right. That had to be quite painful for you (fx ribs post MVA).

Daytonite, BSN, RN · May 21, 2007

Just wondered what kind of response I might get from this title.
Yes---I was a part of several on the night shift. They usually involved 80+ year old people with terminal illnesses who had idiot families that wanted them coded aka tortured before they went to Jesus.

Nursing angels of mercy lurk behind just about any hospital privacy curtain ready and willing to drag their feet in some potential code situations. Those who do it are, in effect, breaking the law. Whenever this subject was brought up in most every hospital I worked, there were very heated discussions that always ended with the people in charge telling us "There is no such thing as a slow code."

As a hospital supervisor I had to intervene when a couple of nurses actually paged me to consult on whether their patients were slow code candidates! Two very intelligent RNs got into a heap of trouble for standing at an apneic/pulseless patient's bedside looking at their watches and counting time before they were going to call his code blue. Their CNA paged us supervisors to tell us what was going on and a code was called immediately for the patient. The patient did die even though CPR got started too late and the family demanded an autopsy because of his unexpected death. These two RNs didn't know the entire story on the patient and his illness. Their pity over his condition was miscalculated because the whole story wasn't in the chart--the whole story is never in the chart. They were fired and reported to the state BON. As a unit manager I would have given any of the nurses under my supervision correction for referring to the relatives of one of our patients as "idiot families". That is an inappropriate assessment for any professionally trained nurse to be making.

MrsWampthang, BSN, RN · May 21, 2007

Just curious, is there some sort of training you can take to learn how to talk to families about their loved ones prognosis? I.E. Can you learn to say the words that will help families to let their dying family member go if there is no longer any hope rather than keeping them as a full code? I'm just wondering because I have had at least one patient pass away on my shift that we coded, lost, but never should have been a full code in the first place. He was on dialysis, very end stage renal disease, to the point that you could walk in his room and smell death.

I have seen so many patients like this, in even worse shape, that are being tortured daily with dialysis, TPN, ventilators, tube feeds, etc. (These are patients that are being kept alive, not those that have any quality of life at all.) I just wish I could say something to these families that would help them see how they are literally torturing their loved ones by not letting them be free of their weary, disease ridden body.

Ironically, I work as night shift PCC, and have had 6 patients pass away on my shift in the last month. I feel like Nurse Death! Five of those were DNRs though and death was not surprising, just not expected. In all cases, death was a blessing.

I was able to help my dad see that in my mother's case, and the nurses that took care of her were so supportive of all of us, as well as her doctor, who called me long distance to discuss with me her medical condition.

Anyway, back to my original question, is there any training you can get to help families make a humane decision that they can be comfortable with? I;m not even talking about terminal weans, which are a whole 'nuther situation, just helping families to see that making their loved one a DNR is really the best thing for that patient.

Thanks,

Pam

TazziRN, RN · May 21, 2007

Actually, it's not our place to have those conversations, Thang. The docs should be doing that with the families. We get involved only when the family asks questions.

queenjean · May 21, 2007

Why not?

Because he felt her sterum disintegrate beneath his hands; when you put your hand on her chest while they were bagging her you could feel all sorts of crepitus. She was a skinny little thing, you could see things weren't right without even touching her. There was no need for a chest xray, her sternum (and ribs, too, you are correct) were in pieces. She was physically unable to withstand CPR. That's what I mean by she was not medically able to be coded successfully. I would have felt very wrong performing chest compressions on her. Obviously the physician felt the same, because he called it pretty quick.

queenjean · May 21, 2007

There are all sorts of continuing ed classes and conferences on death and dying. Any sort of palliative care conference will discuss this.

I would disagree that it isn't our place to discuss this with the family. Often this has been discussed with the family exhaustively, by the physician, social work, chaplin, et nursing staff. And still there are questions, follow up questions, and they seem to often want them answered at three a.m. Having some guidance et education on how to discuss these issues, to reinforce the previous teaching and discussions, is very helpful, I think.

I don't have as much experience as many here, with death and dying. Our floor is an acute care medical floor. We don't code that many people. If they start to head south, we either send them to ICU or, if appropriate, the palliative care unit. The implementation of a rapid response team has decreased our codes even more. I feel like I have quite a bit more to learn in terms of supporting families during this time. I'd like to attend the palliative care conferences in the area, but so far all the CEU-offering conferences have fallen on bad weekends for me. I wish our hospital would do more to help those of us on the floor with this. Their standard line is that, if we are uncomfortable with answering the questions, we should refer them to the physician, social work, et/or chaplin. Yeah, in theory. But when someone's having a crisis at 2 am, I can't just tell them I'll refer their questions to social work. Who won't be here for two days because they don't have weekend hours. The doc on call isn't their physician. Basically they are left hanging.

I feel very inadequate in these situations. I suppose some of that will simply resolve with more time and experience. But I hear your pain, Mrs.Thang. I'd like a little more guidance on talking to and supporting patients and their families in these types of situations.

TazziRN, RN · May 21, 2007

I would disagree that it isn't our place to discuss this with the family. Often this has been discussed with the family exhaustively, by the physician, social work, chaplin, et nursing staff. And still there are questions, follow up questions, and they seem to often want them answered at three a.m. Having some guidance et education on how to discuss these issues, to reinforce the previous teaching and discussions, is very helpful, I think.

I believe that's what I said.......

queenjean · May 21, 2007

Age does not matter.

I think age does matter in terms of ability to heal from the physical effects of a code; so does co-morbidities. I would never NOT code someone just because of their age. And we attempted a full out code on this little lady; it was just quite obvious from the moment he attempted chest compressions that her body was physically unable to be coded. At that point, there wasn't much good we could do. I still feel that way.

queenjean · May 21, 2007

I believe that's what I said.......

Sorry, I guess I misunderstood you.

Editorial Team / Admin · May 21, 2007

Because he felt her sterum disintegrate beneath his hands; when you put your hand on her chest while they were bagging her you could feel all sorts of crepitus. She was a skinny little thing, you could see things weren't right without even touching her. There was no need for a chest xray, her sternum (and ribs, too, you are correct) were in pieces. She was physically unable to withstand CPR. That's what I mean by she was not medically able to be coded successfully. I would have felt very wrong performing chest compressions on her. Obviously the physician felt the same, because he called it pretty quick.

The point I'm trying to make is that just because there are complications of CPR such as fx ribs, etc., one continues compressions.

CPR is ineffective w/o compressions. Result=death.

There is not a medical indication written to halt CPR just because the compressor fx ribs/sternum.

I'm just trying to educate that fx ribs, etc. is a complication of CPR and does not warrant stopping/slowing down/letting up on compressions.

I totally understand what you are saying in regards to the condition of the patient with poor prognosis and no possibility of a successful outcome regarding CPR. As for the physician calling the code, I have to agree with that.

Daytonite, BSN, RN · May 21, 2007

. . .is there any training you can get to help families make a humane decision that they can be comfortable with? I;m not even talking about terminal weans, which are a whole 'nuther situation, just helping families to see that making their loved one a DNR is really the best thing for that patient.

I'm not sure about any specific training with regard to this. A course or book on thanatology might be helpful. My guess is that like most skills in nursing it takes rolling up your sleeves and digging in, correcting your practice from errors you make, searching out reading material for more information and always being ready to make another go at it.

Your post sent me to my care plan references and I was particularly looking at the ones pertaining to death and readiness for death. Some of the nursing interventions (and these are independent nursing actions) mention helping the patient to redefine their main life goals, adopt realistic goals and recognize ones that are impossible to achieve, help patients with life review and reminiscence, encourage them to express their feeling of fear and validate it, to help with making contact with death planning organizations (funeral arrangements), encourage the patients and family to talk with appropriate professionals about areas of concern and teach them about options for care and such things as advance directives. If we were in nursing school we would be told to explore any resources we could find on these interventions to find out more about how to initiate them.