Slow Codes

all4schwa · May 20, 2007

My first code experience was last night. At 1905, shiftchange of course. The patient was a DNR, but not expected to go (ie. had been amb in the halls, ect). I guess when it all went down, the dtr started yelling to 'do everything' All she needed was one shock, no meds and they held off on intubation while the doc talked to the family. They went ahead with their DNR plans and left her on my unit, and my assignment of course. The lady was completly fine and was complaining about the dinner, wants a baloney sandwich, but she hurts like hell. So, after the second painpill, I make sure they are aware that she will have some pain (she had pain before the incident) because she had been shocked. The pt hears this and is in disbelief. I dont think that I realized that maybe she didnt know any of that had happened!

btw, I walked her to the br before I left and started having this huge coughing fit on the john, I thought it was over for sure........

WolfpackRed · May 20, 2007

Nursing is considered, according to recent polls, to be the most ethical profession. I like to think that we are ethical because what we say we will do. That means that if someone is a 95-year-old full code with poor prognosis, cancer, etc I still plan on coding them appropriately with high quality CPR. Yes, it makes me upset when I see family member's interfering with the decision or physicians who don't properly explain actually what CPR involves and the chance that they may not survive anyway. However, it is our responsibility to provide honest care for patients and their families. To me, a slow code is neither honest nor ethical.

But nurses are also bound by the moral principal of nonmaleficence, as well as fidelity and veracity. So, if the CPR will do more harm than good, should we have the right to say that we will not participate in it?

karenna · May 20, 2007

I must have worked in the worst hospitals ever. Slow codes on the floor were not out of the ordinary in certain situations.

TrudyRN · May 20, 2007

In my 20+years of nursing I don't think I have seen many terminal patients that were aware one way or another being coded.
That you know of.

jmgrn65, RN · May 20, 2007

I personally think it is illeagal and unethical. Having said that there has been times that I have thought it appropriate for some patients. But when it came down to it, you still have to do what is required. Just my :twocents:

TazziRN, RN · May 20, 2007

I have participated in several over the years. In each case it was well-thought out and the house supe would go around quietly to each member of that day's code team and ask "Do you have a problem with this?" If anyone had said Yes he/she would have been replaced so as not to place that person in a difficult position, but I've never known anyone to have a problem with it.

I don't consider family members ignorant when it comes to deciding about DNR status. Letting your parent/spouse/child go is the hardest decision to make for most people, even when they know what a code consists of.

angel337, MSN, RN · May 20, 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.

it is not our place to put value on someone else's life. my grandma means the world to me and if she was terminally ill, i would not want to see her suffer but at the same time i would not want an "idiot" nurse telling my family other wise. believe it or not families are aware of what they are doing but letting go can be hard. as a nurse it is my job to be as empathetic as possible and not judge the intents of the families decision.

muffie, RN · May 20, 2007

so as a nurse and family member, have these discussions with your families, clear the air and get your health care directives updated and current !

DutchgirlRN, ASN, RN · May 20, 2007

I think that calling the families "idiots" is ignorant. These families may very well be uniformed about how traumatic coding someone can be, or perhaps, they just see their mother, or husband or wife, etc. in that bed and cannot bear the thought of letting him/her go yet.

No so much idiots as selfish. The most unselfish families I have seen know when enough is enough and turn loose of their loved ones and let God make the decision.

Years ago (25+) slow codes were very common on night shift with terminal patients. Not so much on days because the family was always around. There were times when we asked them to leave the room, shut the door and then went to a slow code. I went along back then because these patients were so pitiful and bringing that back was downright cruel. We didn't fully understand the legalities or ethics involved...or at least I didn't.

In the present, I would refuse to do a slow code even if the patient had terminal CA. I would hate coding this person but I would do it because legally it is the only right thing to do and we can't make moral judgements for the patient or the family.

I have made my wishes clear and so have my parents and I intend to honor them.

scattycarrot, BSN, RN · May 20, 2007

As far as I am concerned a patient is either for resuscitation or not for resuscitation. And if its the latter than they have a formal DNA card filled out by the relevant doctor and filed in thier medical notes. Its not for us or the medical team to make an on the spot decision about someones quality of life. maybe that patient ,who to us has terminal CA and no chance of survival, has not given up hope that one day they will get better,or conversly, maybe they HAVE decided enough is enough....but thats not our call! Just my opinion,wharever its worth! Tricky ethical area this!

Jo Dirt · May 20, 2007

I think that calling the families "idiots" is ignorant. These families may very well be uniformed about how traumatic coding someone can be, or perhaps, they just see their mother, or husband or wife, etc. in that bed and cannot bear the thought of letting him/her go yet. I understand how frustruating it is to have patient with a terminal illness a full code. I work in MICU/SICU and see it all the time. So, I guess what I am trying to say is that I think it is an unethical practice.

I appreciate these words of wisdom from a 92 y/o LTC patient as she watched a family *insist* the CNAs assist(lug and carry) an incontinent wheelchair bound patient(her roomate) to "ambulate" to use the bathroom: some people just don't realize when it's time to give it up.

When you have an old, tired frail patient who just wants to be left alone to let nature take it's course and you have an irrational family who is in denial I think that family needs a wake up call, no matter how harsh and cold it is. They don't need to be coddled because they can't bear the thought of grandma not being with them anymore, what they are doing is incredibly selfish. I have seen the undue stress it puts on old and sick people when the family hounds them to " try." I used to understand but over the years I am understanding less and less. There are times when it is really time to just give it up.

shellsincanada · May 20, 2007

When my Dad was dying (sudden event even though he had multiple long term heart problems) my family was divided on what needed to be done.

It was decided for us. The ICU team basically said- we are extubating and we are not resuscitating when he codes. It was clear after the 24-48 hours after the cardiac arrest he wasn't going to regain consciousness and the prognosis was nil. They had us get comfortable with their decision but it wasn't our decision. Thankfully. It made things much better I must say.

There have been a few court cases regarding DNR's that aren't wanted by the family. There was one that basically said

"Neither consent nor a court order in lieu is required for a medical doctor to issue a non-resuscitation direction where, in his or her judgement, the patient is in a irreversible vegetative state."

This is in Canada BTW. I think personally this way is incredibly more ethical then the "slow code". I remember my first code as a new nurse. It shocked me. It was someone who should never have been coded. The docs and nurses were chatting and doing compressions- we would get a pulse back and then sit and wait until she coded again. They thought it was a good learning experience for me but all were in agreement that this was appalling. Either do a code or not. It is either our decisions as medical personal or it isn't.

edited to add that ALL patients in nursing homes in the province I am are DNR- they will not start doing compression. If you want they will call an ambulance but they never start a code. All patients are aware of this and choose which level of dnr they are.