Stopping a code w/o MD

[Bug Out, BSN]

I heard an interesting story today.

Facility is a SNF, Pt codes, family at bedside, after a few minutes of the code the son, Med POA, requested to stop the code. The person running the code a LPN refused to stop citing a rule that once the code starts it cannot stop until medics arrive. Unit manager, RN, starts screaming at the LPN to stop the code in between the son's pleas to stop. Medics arrive, take over the code and immediately stop.

If the POA requests an ongoing code to stop can it be stopped without the medics or a MD present?

[TheCommuter, BSN, RN]

If the SNF patient does not have a DNR order on his/her chart, the code continues until the EMS personnel arrive and take over. In the nursing home/skilled nursing facility setting, the floor nurses do not have the authority to stop a code once it has started. Only the paramedics can make the call to stop the code in this type of workplace setting since there are typically no physicians present in nursing homes.

[Bug Out, BSN]

If the SNF patient does not have a DNR order on his/her chart, the code continues until the EMS personnel arrive and take over. In the nursing home/skilled nursing facility setting, the floor nurses do not have the authority to stop a code once it has started. Only the paramedics can make the call to stop the code in this type of workplace setting since there are typically no physicians present in nursing homes.

I understand that the Nurses would not have the authority to stop the code but the family does not have the authority either?

[brownbook]

I forget the exact wording but legally yes once CPR is started you should continue until you are exhausted, are in danger, or medical personnel take over. But regardless of whether or not the family had POA, even if they didn't, common sense with an ?obviously? frail elderly adult in a nursing home nearing the natural end of their life a code is called and family says please stop the code I say stop! What is the worst case outcome? The family is going to sue you because you didn't save their loved one? The police are going to investigate a suspicious death? We can argue legal precedent all day which unfortunately seems to carry greater weight than common sense!

[TheCommuter, BSN, RN]

I understand that the Nurses would not have the authority to stop the code but the family does not have the authority either?

Once a nursing home code is in progress, the family members do not have the authority to put a stop to it. After all, it was typically their decision to make the patient a full code, and they cannot back out of the decision once we are actively coding the patient in a nursing home or skilled nursing facility. The time to back out of a resident's full code status is BEFORE it happens.

All of this could have been prevented if the family member had made the realistic decision to make the resident a DNR prior to something of this nature occurring. Many families do not realize that codes on elderly patients with multiple chronic disease processes are brutal to their frail bodies and frequently do not improve any outcomes.

What is the worst case outcome? The family is going to sue you because you didn't save their loved one?

Unfortunately, nursing homes and skilled nursing facilities are frightened of litigation, so many of the policies that we must obey seem rather arcane and silly. The facility could get sued if we put an end to a full code in progress. The facility could also get slapped with a lawsuit if we accidentally initiate CPR on a resident with DNR status. We're damned if we do and damned if we don't.

[canoehead, BSN, RN]

The medical power of attorney (with papers in hand) has the same authority as the patient to stop any procedure. I would stop a code if they requested it.

[CT Pixie, BSN, RN]

In a LTC facility once a code is started it CAN NOT be stopped until the medics arrive and take over. Once the medic is there, it is his/her call, since they are now responsible for the patient. Even if the POA/person in charge of pts health decisions/family members are there and state they want it stopped..once it starts..it can't be stopped, the RN, house super, DON or ADON do not have authority nor can the demand that a nurse stop CPR once its started.

Now, that being said, a full code status may be changed at any time (with the exeption of once the code is started), by simply signing a DNR paper.

[shiccy]

To be the devil's advocate, I'm sure this isn't the case in EVERY state, as each state is different.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

Lost count how many states I've worked in, ER RN and EMS. All say the code continues until EMS takes over. Nurses can only stop a code in progress as brownbook stated, or on an MD's direct order. The RN unit manager let her title go to her head. EMS works under medical directors standing orders and often are in direct contact with an MD via radio. POA shoulda manned up and signed the DNR papers before the code.

I hate this sytem, but it's what the laws dictate. Despite POA, if one family member, even out of state, disagrees with stopping the code, you'll spend some "quality time" with lawyers. Once in court, it's always easier to defend acting in favor of life.

[netglow, ASN, RN]

That must have been really, really, rough on that RN -- all that going on...

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

If the RN knew here scope of practice and the legalities of her position, as she is obligated to do, she could have remained calm and explained things to the family. Lacking a DNR order, resuscitation is required unless an MD directly orders it stopped.

I participated in a code in a Maine ER, with the POA present and protesting, because a relative in California was on the phone threatening legal action. In the end, metastatic brain cancer after a very long life took the decision out of mortal hands.

Both nursing and EMS personel take their orders from physicians. Neither is allowed to practice medicine. Important to remember in unusual circumstances.

[steelydanfan]

If the pt. is a DNR per decision of the POA, the out of state relatives can protest till the cows come home, it DOES NOT change the legal standing of the POA to make a decision. Any legal grievance by a "relative" is moot, and I would not worry about having to defend any actions. It would never even get to discovery.