Slow Codes

[karenna]

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.

[scattycarrot, BSN, RN]

I'm very grateful for the medical director of the SNF in which I work. He leaves our old ones alone. When there is nothing to be done but relieve pain he doesn't send them for tests, doesn't ship 'em to the hospital, he leaves them with us, in their home, and we can let them die peacefully, in their own beds.

Thats fantastic. I cannot tell you the amount of times that we have had patients arrive in the ER from nursing homes,etc...that are literally dying and they have been sent in for us to code them. Usually, after getting a history they will be signed DNR and end up dying a few minutes or hours later in hospital, on their own, away from their own bed. Where is the dignity in that? I always feel so bad for them when that happens and I can still remember most of the patients who have died that way. Not their names but just the way they looked....scared and alone.

[banditrn]

It's interesting how everyone in this country (including most health care professionals) see a full-code as a God given RIGHT that patients/families have. I realize that in a legal sense it can be. But in an ethical sense I'm not sure that I agree with that.

As health professionals, I wonder if we should ever just sit families down and tell them that their family member is terminally ill and if their heart were to stop there would be nothing more we could do for them. Is it really ethical to force families to make a DNR decision in those cases? They're hearing "Do we save your loved one's life or do we stand there and do nothing?"

It's just expected that families should have the full option of us doing EVERYTHING known to medicine on someone who is ready to pass on. I wonder if that's really the healthiest way of looking at life and death issues. Everyone keeps saying it's the families' decision and I see their point in a sense, but in another sense, does giving them unlimited financial and life and death power in a medical setting really make ethical sense either? Maybe medical resources are limited and peoples' lives are also limited and we should accept that a little more readily within our culture in order to do the greatest good for the highest number of people.

I, personally, hope for a dignified, peaceful death when my time comes. That is becoming more of a rarity. A lot of the deaths I see are very drawn out and very frustrating and scary for everyone involved. I just don't agree that we're alway doing the families big favors by putting them on the spot to make impossible decisions. We give so many people false hope and, in the end, guilt and self-doubting about their loved one's death.

I guess, in short, I'm trying to say that I think the entire system has giant ethical flaws. So, to say that you must follow The System correctly in order to be ethically correct doesn't make sense to me.

With that said, I work in an ICU and when someone codes we always do a real code. To cover our asses, you know.

Excellent!!

[Rnandsoccermom]

I for one remain chronically amazed that civilization (and I use that term loosely) have not come to terms with the idea that we are all living to die. Death is as much a part of life as birth and living yet we just can't seem to wrap our minds around it and embrace it. My mother-in-law finally passed recently. She refused to sign a DNR and left the decision making to be left up to the kids, which were a 3 to 2 vote. The 2 that wanted mom to have a full code, were not as educated as the other 3 and also were the ones that did not want to do any of the daily home maintenance work to help take care of her. The whole thing was a mess. Mom accidently died late one night. I'm pretty sure she was a "slow code", thank God!!

The slow code may be unethical and or illegal, but because we do not have laws in place that require all patients to make a clear decision in writing, the slow code helped everyone make the best decision. The end result would have still been the same, keeping her alive would not have solved her health issues, it would have just prolonged the situation.

I agree. The question that really needs to be asked in some of these situations is are we prolonging life or prolonging death? Futility is futility and frankly what I struggle with in some situations is that what we are doing could be construed as torture. Some of our solutions are sometimes cruel experimentation in the last minutes of someones life, unfortunately. Ugly but true.

[Roy Fokker, BSN, RN]

As I read through this thread, I am constantly reminded of the dictum:

"All laws should be moral. But not all morals should be law".

Very interesting thread.

cheers,

[queenjean]

I remember the last slow code I was in; the nurse went to do chest compressions and we all heard this horrible CRACK and he jumped back, looked at her chest, and said, "Well, I think I just made sure she's a DNR." She was a 90+ year old little lady with horrible osteoporosis. He was pretty sure he broke her sternum in several places. We just slowly coded her at that point; we couldn't do chest compressions. We went for about 5 minutes and then called it.

Regardless of the ETHICS of whether this woman should have been coded or not, the MEDICAL REALITY was that we could not code her. Why is it ethical to code a person who will not survive or who will not survive without terrible consequence; but it is unethical to transplant a new liver in a person who is an alcoholic? How is it different? If a person's life will be worse after the code, why would we code them? If a person needs a liver, regardless of why and what will happen afterward, should we not provided it? Of course not. Why would we waste the liver, waste the time and money, and put the patient through a transplant that they probably won't survive? So, why is it okay to do that in terms of a code?

My grandfather was a no code, but my mother freaked when he went into a sustained vtach and looked like he was having seizures and commanded them to code him (screaming terms like "lawsuit"). My grandfather was in end stage CHF. Terminal, as it were. So, they code him, he survives, and spends SIX WEEKS in an ICU in renal failure, heart failure, incontinent, not even oriented to self, and intermittently on a vent until he died. Great. His last 6 weeks were horrible, and a terrible use of health care resources. Why the hell did they not slow code him? I wish they would have.

Even my mom realized what a fool she was (too late, of course). Interestingly enough, to hear her tell the story now, she blames the nurses and doctors for going along with her. Now she'll say that they should have respected his wishes. Im' always like, Yeah, you were a wide eyed screaming banshee, threatening lawsuits and they ended up having to call security on you. How about taking some responsibility for your actions and your ignorance in regards to the consequences of your outrageous demand?

[sirI, MSN, APRN, NP]

We just slowly coded her at that point; we couldn't do chest compressions.

Regardless of the ETHICS of whether this woman should have been coded or not, the MEDICAL REALITY was that we could not code her.

Why not?

[TazziRN, RN]

Why not?

With a fractured sternum???

[sirI, MSN, APRN, NP]

Impossible to know that and probably was fx ribs.

But, the point is, if no compressions, not a chance for survival.

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

[TazziRN, RN]

Impossible to know that and probably was fx ribs.

But, the point is, if no compressions, not a chance for survival.

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

I agree with Queen, but then I am not against slow codes either.

[SuesquatchRN, BSN, RN]

I think siri's point is not about slow codes per se, but whether is was possible to code this woman.

[sirI, MSN, APRN, NP]

Thank you, suesquatch. That's exactly what I meant. I did not intend to make reference to slow codes. Just wondering why compressions could not be continued???

[TazziRN, RN]

Ah, I see. Sorry.