Slow Codes

CHATSDALE · May 21, 2007

muff was right about addressing this preneed, and age doesn't matter, i have had a brain dead 20 y/o after a jack hit his head while changing a tire

as a nurse you are an educator too and encourage your patients to make up their own mind about what they want..tell them there is no right or wrong but that it should be there in black and white so grieving relatives don't have to make that kind of decision in a stress driven time

i think that the decision that all people in nursing homes should be a dnr is gross . that is something that should be decided on a case by case basis

families that don't make the decision [dnr] in the face of reality are not really ignorant or selfish for the most part, they just have not reached the 5th step of acceptance...not everyone in the family will reach that point at the same time..again that is eased if wishes are formed by patient ahead of time and if one person is given the authority to make decisons

back to op, it has been years since i have seen a 'slow code' they were frequent when i first started nursing but they were never written they were usually agreed by md/staff..but now they are not legal and if you do something when you don't have a legal leg to stand you stand a very good chance of losing your license and then you won't be any good to any other patient

i have partiipated in codes post cabg when the sternum was split from here to there sometimes you do what you have to do

tytkhat · May 21, 2007

I remember my second year as an LPN on a med surg floor, we had a client in his mid 90s that coded. There were not enough RNs and so I as called to do compressions. Well, needless to say I was traumatized after I cracked several ribs but continued compressions as if he were 60 years younger. One of the RNs giving meds said to me after the code was over (did not make it), that I did not have to compress like I was trying to bring him back, as they were considering a 'slow code'. Of course this infuriated me and I told her that that was BS-either the pt is a FULL code or they aren't, and I dont recognize the term 'slow code'. The attending overheard our chatter and intervened, agreeing with me fully, saying that if you participate in a code, you have to advocate life and fight for the pt, otherwise why bother with sub-standard morals and practice...wow.

Rnandsoccermom · May 21, 2007

Unfortunately, sometimes families will not make their family member a DNR out of guilt for not being who they should have been when that person was well. Seen it happen too many times.

Was at a code recently, 78 year old, multiple comorbidities including chronic renal failure, htn, diabetes, CAD, PVD, hospitalized for a month. Unresponsive, trached on a vent, maxed on Levo, Dopa and Phenylephrine. Became brady-asystolic 3 times in 2 hours. Pumped epi and atropine in, did CPR. Skin cold, extremities mottled. Spoke with family 3 times regarding the codes and changing the code status, they refused.

It was sickening and inhuman. Say what you want, we were not helping this patient, only prolonged the inevitable. We are human, not gods, we can't fix everything. Knowing our limitations is just as important as knowing our capabilities. I would have participated in a slow code in a heart beat in this situation.

Daytonite, BSN, RN · May 22, 2007

Unfortunately, sometimes families will not make their family member a DNR out of guilt for not being who they should have been when that person was well. Seen it happen too many times.
Was at a code recently, 78 year old, multiple comorbidities including chronic renal failure, htn, diabetes, CAD, PVD, hospitalized for a month. Unresponsive, trached on a vent, maxed on Levo, Dopa and Phenylephrine. Became brady-asystolic 3 times in 2 hours. Pumped epi and atropine in, did CPR. Skin cold, extremities mottled. Spoke with family 3 times regarding the codes and changing the code status, they refused.
It was sickening and inhuman. Say what you want, we were not helping this patient, only prolonged the inevitable. We are human, not gods, we can't fix everything. Knowing our limitations is just as important as knowing our capabilities. I would have participated in a slow code in a heart beat in this situation.

I totally understand and have seen what you are saying. I stood by in helpless horror as one of my patients stopped her dialysis treatments and was dead in a week. I worked on a stepdown unit where we had a vegetable patch of patients that lingered for days, weeks and months, many full codes. However, if you are heard AND witnessed doing this slow code business by someone who is liable to blow the whistle on you then you can kiss your license and your nursing career good-bye. A place like this forum where we are anonymous might be a safe place to admit what we truly feel, but I wouldn't be so arrogant and proud to announce something like this to coworkers.

What my mother, who was an ICU nurse, and I learned from seeing all this kind of stuff at work was to have durable powers of attorney put in place for ourselves, know our families are aware of it, know who among our families does or doesn't agree with it and make sure we have physicians who are going to honor our wishes. Yet, I can't tell you how many nurses I've worked with who haven't done this or who have a spouse who has openly told them that they would do everything possible to keep them alive if they were in that situation. Over my career several of the big right to die cases were national news headlines, one geographically close to home, and it lit a fire behind me to get my documents in place. It still amazes me that many nurses still haven't worked this situation out in their own lives. We have no right to make that decision for the patients we care for and, yet how many have finalized and committed to that decision for themselves which they do have the absolute and legal power to do?

ShayRN · May 22, 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.

I understand your feelings, I really do! As a Hospice nurse, I think the most couragous thing you can do is let nature take its course. Just because we can keep some people alive, doesn't mean that we should. HOWEVER!!!! My mother has told me more than once that she wants everything done, no matter how hopeless the situation. So, I will honor those wishes to the best of my abilites. While I would probably look the other way if I found out about a "slow code, " I can assure you my stepfather wouldn't. :nono:

Rnandsoccermom · May 22, 2007

It's very hard when you work in areas where people die every week, some peacefully, some not so peacefully. My husband is a RT and we both are in agreement about what want in the end.

As for me, my parents have told me since I was 17 not to keep them alive if there is no chance for meaningful recovery. They stopped my grandmother from being coded. My husband was DP for his mother and father and they were both DNR's. His father died after complications after CABG and his mother after a long cancer battle.

As children though, we were taken to wakes and funerals and were always made to understand that death is part of life. I have done the same with my own children.

scattycarrot, BSN, RN · May 22, 2007

i think that the decision that all people in nursing homes should be a dnr is gross . that is something that should be decided on a case by case basis

I never said that ALL patients that came in from Nursing Homes were signed DNR. I seem to remember that I said that when they came in a full history was taken by the doctor(case by case basis,no?) and USUALLY (not always) they would be signed DNR. Its never a case of 'oh,they are Nuring Home patients...just put them over there and we will wait for them to kick the bucket'. They get the BEST care usually and you know what, sometimes the best care for that individual patient is doing nothing and just letting them die without being jumped up and down on and having thier dignity taken away from them in the worse possible way.

The most important point here,I think,is that decisions are made and the proper procedure is followed, eg.. making the patient for or not for resus after examing all the facts. With slow codes, there has been no following of procedure as they don't officially exist. Either resus or don't. Just my opinion.

shellsincanada · May 22, 2007

i think that the decision that all people in nursing homes should be a dnr is gross . that is something that should be decided on a case by case basis

It is the policy of the nursing homes here in Manitoba to start CPR on any patients. Patients choose the level of DNR when they enter the nursing home( all levels are treated for symptoms and pain etc, some levels are more aggressive)

If they want to b be a full code- the home can call the paramedics and they will start cpr( really I suppose this is a form of a slow code in reality) once they arrive. Or they choose not to enter the home as a resident. The nursing home makes it pretty clear that this is the policy. Nothing hidden there.

scattycarrot, BSN, RN · May 22, 2007

Ah, I apologise to Chatsdale as I assumed that you were referring to my comments about Nursing Homes. However, I see I might have been mistaken? I am a bit confused(doesn't take much!)...is it policy (officail or not) then in some places not to perform CPR on a Nursing home patient??? I have never heard of that.

RNperdiem, RN · May 22, 2007

Sigh. Were things easier when no pulse and no breathing simply meant dead? Despite CPR, the dead tend to stay dead. I do not approve of the slow code either.

Jo Dirt · May 23, 2007

Easier said than done! My parents just don't want to have this discussion at all!

15 yrs. ago, my mother and me were in the waiting room while my dad was in for his second triple by-pass. About 4 hrs. into the surgery a nurse came out to talk with us. We expected to hear everything was going well, but instead she told us the surgery was NOT going well. Of course, it was like out heart dropped out of the bottom of our stomachs. Then, the nurse asked is my father had any kind of living will or advance directive. My mother was totally appalled and offended that she would have the nerve to even ask such a thing, started waving her hands in the air and shaking her head. Talk about major denial. He survived the surgery but the next five weeks he was basically strapped to a bed and kept sedated until he died. But we kept hope until the very end 5 weeks later when my mother finally was forced to accept the inevitable and give the okay to remove the life support.

So I know what it is like to be on both sides of the fence.

Whew, this is a stressful topic.

TazziRN, RN · May 23, 2007

{{{{{Mama}}}}}