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  1. BodhiHeart

    Medical Futility

    When do you accept that it is futile to code or prolong a code? I had a patient maxed on 5 pressors. He was saturating in the 70s on 100% vent settings and gradually dropping lower. He ended up being coded twice. It was a combined time of over an hour of CPR. I felt like the patient was being tortured half way through the first code. He ended up dying anyway which I felt was the obvious outcome from the onset. Am I wrong to feel this way? No one else seemed bothered by it.
  2. I'm 66 and on Occupational Health Nurse Manager at a Fortune 500 company. In November one morning I woke up unable to stand on my right leg. Subsequently I was hospitalized, had a MRI then a CAT and given an spinal epidural of steroids whereupon I recovered over the next two months. I have severe bilateral neuroforaminal stenosis. This was quite to my surprise as I work out regularly in the gym (aggressively which may have caused the issue) and my lumbar radiograph is none to pretty. I returned to work half days and my doc said: "What do you want for restrictions?" I answered: "Stand no more than one minute; Walk no more than 5 minutes and No lift/push/pull greater then 7 lbs. Well, I was at work for about two hours and someone came running into my clinic: "Come quick, someone is having a heart attack." Indeed, that appeared to be the case. I said to one of our first responder team: "I can't do compressions, you do compressions, I'll bag." We did exactly that. The person giving compressions did an excellent job, we ventilated him, I shaved, slapped on the pads, analyzed and shocked. I thought we might save the fellow because of "shock advised," but it wasn't to be. It was great teamwork and I'm proud. However, my CPR card just expired and now I must get a AH CPR card but I should not do compressions. Since CPR is an essential function of the job, I could be terminated because of this. So I wonder, am I covered under ADA? I'd argue yes, as I would never be doing CPR one on one and there would always be another first responder to do compressions. Any thoughts? Anyone face this sort of issue before?
  3. OIFSapper

    ED Shocker

    So I am an ED RN at a large hospital in St Louis,MO. I started my career later in life in my early 30s. I am a 15 year Disabled Army Veteran with 2 tours in Iraq. I am currently 37 years old. I am a loving husband and have two beautiful daughters that I love dearly. I have great faith in God and try my best to impact the lives of those around me. I was part of a Unit that did Roadside Bomb removal and due to a shortage of medics were cross trained to be a combat life saver placing IV lines, needle-chest decompression, tourniquet and dealing with amputations and sacking chest wounds. I ended up being fairly good at all of those and it inspired me after a long road of recovery to use my GI bill and go to school to become a RN. I faced a lot of adversity dealing with residuals of traumatic brain injury and a processing delay and through a lot of therapy and treatment passed an accelerated program with a respectable GPA. I started my career in a Trauma/Neuro ICU fellowship and had to step back after a while as it was a little too close to home with my combat experience and also having some cognitive delay from a TBI I felt concerned that in 12 hours of non-stop chaos I couldn't keep up mentally and didn't want to hurt anyone. After a long search through multiple different areas in nursing I have found my love. The emergency department at night has just enough chaos to feed the adrenaline junkie in me but has such a variety that it isn't just 12 hours of titration to keep people from death. To be honest in all my time in the unit I never had my own patient crash and only assisted with codes of others. Two weeks ago in the ED I had my first code since the military and it was a patient I never expected to go that route. I'll spare the details to keep privacy but long story short after reviving and getting up to the ICU they coded again and ultimately died. Once I got back downstairs I took a moment and went outside of the ambulance Bay in the wee hours of the morning to take 5 and decompress. I felt weird. I was uncomfortable in that post CPR moment. I remember the absolute shock of the patients wife's blank expression as she just didn't even process that I was breaking ribs and crushing her frail husbands chest trying to save him as the DR tried to intubate. After I wanted to go give her a hug and console her as she was waiting in The ICU waiting room for an update but I just couldn't do it. I had to go back downstairs and try to process what had just happened. I wouldn't know what you say anyway. I have never had an adrenaline dump like that and soon found myself puking in the bushes and choking back tears. I was shocked! This isn't like me. Is it always like this? I felt like it was hard to let go of it. I am OK now but the impact was much more than I expected. Any tips to help process these moments? I have always counted myself good in chaos and am seldom at a loss for words. I would be encouraged to hear your stories and suggestions so I can grow and learn to deal better in these situations. Much love ... Matt, RN
  4. As a student, the anticipation of a code being called is anxiety-laden, to say the least. In talking with the staff it became apparent that no matter how many times they have been in a code situation it is equally as anxiety causing for them. Since starting on the unit I have witnessed two code calls and have been involved with calling the CCA down twice. Although none of these particular codes involved performing CPR, I decided to explore some of the ethical issues and communication barriers involved with code status. One particular patient was incapacitated and showed little hope for any recovery but yet had full code status. Both I and other staff expressed great concern of how a code would progress should this patient suffer respiratory and or cardiac arrest. In order to fully understand the ethical issues I felt surrounded this situation, I will present a relatively detailed history of the case prior to critically reflecting on the question of code status and CPR. Just over two weeks prior to us caring for our 80-year-old patient, he was admitted to the coronary care unit (CCU) post-MI from a small town hospital. After seeing physicians in our hospital, he was deemed fit for a coronary artery bypass graft, times eight. From what I gathered in the chart, he had a history of hypertension and although recovering from a heart attack he was in sound mind prior to the surgery. On his first postoperative day he went into cardiogenic shock, and eight days later suffered a massive stroke. He required pleural drains, a tracheostomy, a dobhoff feeding tube, and a heparin infusion. Days later he was transferred to the neuro unit with a Glasglow Coma Scale rating of three to six. He was occasionally a six when he would very slightly withdraw his right leg from pain. He was in persistent atrial fibrillation and had plus four oozing edema in all of his limbs. His hemoglobin was dropping and thus we were ordered to administer packed red blood cells. As I cared for him during the night shift I only encountered his family briefly, but while I was in the room I opened the door to any questions that they might have. In spite of my uncertainty with any potential I felt he had for recovery, I was able to explain his medications and need for a blood transfusion. The patient's son expressed hope and excitement at the prospect of his father receiving a blood transfusion, stating "Oh, that's great! That will perk him right up". I was still unsure at this point if he remained a full code because his physician had not yet had an opportunity to discuss it, or if this is what the family wanted. Yet it became clear as the son further went on to talk about the recent death of his mother, and how they weren't ready to let their father go. I felt strong empathy for the family at this point but questioned how forthcoming and honest the physicians involved in the case had been with them regarding not only their fathers minimal or nonexistent chance for recovery, but what code status really means. In addition, I wanted to explore what the nurse's role is in code status decisions with physicians and their families. It seems there is much confusion regarding the term DNR, particularly but not exclusive to patients and their families. Murphy & Price (2007) assert that although succinct descriptions and procedures are available for health professionals regarding DNR orders, they are insufficient. They further that due to our profound emotional discomfort with death, DNR orders are written not often enough or too late. Part of the problem roots in the confusion over what the term actually means. A DNR order is supposed to mean that in the event that a patient suffers a cardiac or respiratory arrest, CPR will not be initiated. A DNR order does not mean, however, that the patient will not receive maximal therapeutic care and be left to die. I would further that it is this miscommunication that leads to families such as one of our patients, to decide they want full code status. They had stated that they wanted everything done for their father, but one wonders if they knew the violence that can occur during CPR in a code situation and the evidence regarding outcomes if they would still make the same decision. Brindley, Markland, Mayers & Kutsogiannis (2002) stated that "Resuscitation was never originally recommended for all patients, and its goal should be to reverse premature death not prolong an inevitable death. The current situation is often to attempt CPR unless it is explicitly refused." While Murphy, Murray, Robinson & Campion (1989) conclude that not only is CPR inappropriate for some patients, elderly patients with chronic or acute diseases rarely leave the hospital alive after CPR. With this patient, we all felt that CPR would only prolong the inevitable and furthermore would have caused undue harm on this patient after a sternotomy and the multiple other health problems he suffered from. With a GCS of three, not only did it seem unacceptable to have this patient on a regular nursing ward and not in intensive care, it seemed unacceptable that this family had not had the direness of their fathers' situation explained to them in a manner in which they could understand. This was evident in their hopes of how a blood transfusion would turn things around for him. They were clearly unaware that he had suffered massive brain trauma from his stroke to which he would not recover. Although it is not a nurse's place to discuss prognosis with the families prior to the physicians doing so, it is my belief that DNR orders have many implications for nursing practice on an ethical level. Firstly nurses have a responsibility to be a patient's advocate and that starts from the moment a patient is in your care (CNA, 2008). Prior to this patient being taken in for this very risky procedure, a nurse could advocate that the physician discuss advanced directives in a family conference, so as the family is not left to make those hard decisions which can often not be agreed upon amongst family members. Robinson, Cupples & Corrigan (2007) assert that is the lack of advanced planning regarding CPR that leads to poor care when people have passed into an advanced stage of illness. Their research suggests that it is most common to postpone discussions about resuscitation until the patient is no longer competent. As it stands it is left to physicians initiate these discussions and research shows that many are uncomfortable doing so, which could be attributed to poor communication skills or a fear that they will undermine patients hope by discussing resuscitation while they are still in the early stage of illness. Robinson et al. (2007) go on to say that it is often nurses who have to take the lead and bring resuscitation issues to the physician's attention. Families deserve to know that their loved ones are unlikely to recover and it is the physicians' responsibility to be honest and openly discuss this. It is proposed that physicians are reluctant to accept that their patients are in fact terminally ill and can no longer recover from what ails them. In contrast to doctors' disease-centered model of care, nurses' holistic patient-centered approach makes them more attuned to getting involved with end of life decisions, as they are likely better informed about a patients total physical condition and preferences (De Gendt, Bilsen, Vander Stiche, Van Den Noortgate, Lambert & Deliens, 2007). Secondly, both nurses and physicians have an ethical mandate for non-maleficence Performing CPR on an elderly patient who has recently had a sternotomy and has no chance of recovering from a massive stroke would contradict our code of ethics. Advanced CPR has been proven to be a violent intervention that can break thoracic bones, puncture and collapsed lungs, rupture pericardial sacs, cause burns and lead to permanent brain impairment (Davey, 2001). I question how we as nurses can continue this practice when clearly it puts us ethical dilemmas. Lazaruk (2006), a CCU nurse agrees that this harsh, life-sustaining intervention does allow patients a dignified death and that CPR actually leads to significant harm to the patients. She concurs that when possible, code status should be address by medical residents as soon as a patient arrives at the hospital. It could become routine practice to allow patients to be involved in planning their care, and empowering them to make decisions about their own end of life care. Storch (as cited in Lazaruk, 2006) stresses that inappropriate use of CPR is an extremely troubling issue if not the most troubling issue for registered nurses. The CNA Code of Ethics for Registered Nurses (2008) compels us to respect the dignity of our patients and advocate for the use of appropriate interventions. Studies show that in Canada nurses are involved in DNR decision making only half or less of the time (De Gente et al.). Despite all the evidence this practice continues. Storch suggests that perhaps the fear of death or failing keeps this practice alive, and I would agree. I think our society is very uncomfortable with the dying process. As previously mentioned, I had also cared for a patient who was CTC status. Unfortunately, this was the first time I had ever seen this. This patient received only treatment to keep her comfortable so as she could pass away peacefully, in a dignified manner, with her family at her side. She too had a massive stroke, although had maintained more function than the patient with the full code status. She had ten daughters who took shifts staying with her, holding her hand and providing care and love for her. I found the whole situation very touching, and it was refreshing to see a family so closely embracing the beauty of death as a part of life. As it turned out some of her daughters were nurses. I suspect that they are privy to the pain and suffering that the healthcare system can put patients through, even when they have no hope for recovery. Obviously, this is a complex issue, but with more education for both nurses and physicians on how to discuss code status and end of life care with patients and their families, we could make it a less distressing part of regular admission. If it was more commonplace and people knew that it was always discussed, then it would cause less fear and decisions could be made in a more timely fashion. I think we need to talk about death as a part of life and start treating all aspects of our patients, not just their bodies. As health care professionals I believe it is our responsibility to be honest with patients and their families so they can make informed decisions and ultimately ease our moral distress and their own. In an age where technology and health care advances can sustain life for so long, perhaps we could ease the fear of death and dying for patients, families, and healthcare providers and allow people to die with dignity. References Brindley, P.G., Marland, D.M., Mayers, I., & Kutsogiannis, D.J. (2002). Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ. 167(4). Retrieved July 26, 2008, from Predictors of survival following in-hospital adult cardiopulmonary resuscitation | CMAJ Canadian Nurses Association (2008) Code of ethics for registered nurses. Davey, B. (2001). Do-not-resuscitate decisions: too many, too few, too late? Mortality 6(3), 247-262. De Gente, C., Bilsen, J., Vander Stichele, R., Van Den Noortgate, N., Lambert, M., & Deliens, L. (2007). Nurses involvement in 'do not resuscitate' decisions on acute elder care wards. Journal of Advanced Nursing 75(4), 404-409. Lauzaruk, T.(2006). The CPR question. Canadian Nurse, 102, 23-24 Murphy, D.J., Murray, A.M., Robinson, B.E. & Campion, E.W. (1989). Outcomes of cardiopulmonary resuscitation in the elderly. Annals of Internal Medicine, 111, 199-205. Murphy, P., & Price, D. (2007). How to avoid DNR miscommunications. Nursing Management, 38(3), 17-20. Robinson, F., Cupples, M. & Corrigan, M. (2007). Implementing a resuscitation policy for patients at the end of life in an acute hospital setting: qualitative study. Palliative Medicine, 21, 305-312.
  5. Details have been changed to protect the patient and her family. The facts of this case are true. The ambulance page pierced the silence. Most nights it could barely be heard over the din of a busy ER, but tonight the snow had fallen in heavy layers and this seemed to keep people in their homes. The nurses, slouched at our stations, straightened to attention upon hearing the dispatcher's voice crack over the radio, "28-year-old female, difficulty breathing, conscious." The address was announced and everyone gave a concerned glance. The call was to a narrow, notoriously treacherous dirt road, high in the mountains on the west side of our small Colorado town. In good weather and broad daylight, it was a 30-minute response time. That night we had unforgiving snow, whipping winds, and a dark, moonless sky. The ambulance crew rounded the corner past the nurse's station, bundled in their coats, and headed out the door. Twenty-five minutes later, we heard the ambulance crew speaking with dispatch. They were hopelessly stuck in a snow drift- forcing dispatch to page another ambulance to the address. Thirty-five minutes later, it was stuck too. The woman was still having difficulty breathing, now admitting to the dispatcher that she had huffed two cans of commercial keyboard dusting spray just a few moments before her respiratory distress began. She stated her heart felt like it was racing. In our small Rocky Mountain community, we have a team of highly skilled volunteer fire and emergency medical services who had also been activated when the initial call came an hour earlier. One of these responders had managed to get his oversized pick-up truck near the cabin where the patient was waiting for help. His voice came over the radio, "Patient is pale, diaphoretic, tachypneic. Her heart rate is 140 beats per minute. She is having chest tightness." He measured her oxygen saturation at 90% on room air. She had no medical history other than occasional street drug use. As per the previous report, he confirmed that she had huffed a propellant just minutes before the start of her symptoms. He made a judgment call - this woman needed the ER right away, so he did a rather unconventional thing and hiked the woman through the thigh-high snow, bundled her into his truck, and began the unpredictable journey to the hospital. On the way, he encountered one of the stuck ambulances and was able to help them back onto the road. Over two hours had passed, but the patient was finally in the back of an ambulance and headed our way. The phone rang and the charge nurse took the ambulance report. The woman's heart rate and respiratory rate were still elevated, but supplementary oxygen had improved her condition. Her heart rate was 105 bpm and her respiratory rate 24 breaths per minute. On a simple mask at 8L, her oxygen saturation was 100%. The EMTs thought perhaps she was having a bit of a panic attack and that the delayed response had increased her anxiety, but they felt that she was relatively stable. We prepared our cardiac/respiratory room, just in case. Everyone was optimistic - this patient was young, relatively healthy, and she was already improving. This was no big deal. The patient arrived. The updated ambulance report was relatively the same. The patient was a slightly overweight Latina female with hot pink hair. Tattoos snaked her arms and calves. She was indeed pale. Smeared mascara was streaked all over her face - she'd been crying. Her initial vital signs were reassuring. Mild tachypnea was present and she was still slightly tachycardic, but otherwise she looked good. The ER doctor working that night was a gentle and highly skilled provider with over three decades of experience. He immediately evaluated the patient upon her arrival and told her he suspected a mild reaction to the inhalant she had huffed with a subsequent panic attack. Reaching for his hand with wide eyes, she said to him, "I feel so scared." He comforted her and ordered labs, an EKG, a small dose of IV Ativan, and a chest x-ray. He assured her we would do a thorough work-up and get her some medicine to help her stay calm. She nodded and appeared relieved. I left to obtain the Ativan, the charge nurse went to get the EKG machine, and a phlebotomist began to set up for labs. As I was preparing to administer the IV Ativan, the phlebotomist began to draw her blood. The patient's heart rate suddenly spiked to 110, then 120. I thought she was anxious about the needle stick, so I said to her, "Try to stay calm, take a deep breath." Eyes wide, she looked at me with pleading desperation and said something I'll never forget, "I'll never do it again. I am sorry. I am trying," she gasped. The monitor began screaming. HEART RATE 186. "SVT," I thought. Then it quickly converted to ventricular tachycardia. And before I could even blink, ventricular fibrillation. She was coding. I snapped into autopilot, a rush of adrenaline hit my body. I checked for a pulse, but it was obvious she had none. I rolled her onto a board and began compressions. The phlebotomist smacked the code blue button and our ER team streamed into the room. We ran the code for 55 minutes before the doctor announced that he was going to talk to her family, who had arrived in the waiting room 10 minutes before. We continued the code while he was gone. When he returned he informed us that the patient's mother, father, and 5-year-old son were in the waiting room. The room fell into a hush. "She has a child?" I asked. I felt totally deflated. There was no promising sign that she was going to make it. The only sound in the room was the rhythmic, mechanical thrusting of the LUCAS machine, an automated chest compression device we had placed on the patient 15 minutes after she coded, relieving the staff of the breath-taking work of chest compressions. The doctor nodded, then said, "Let's continue for another 15 minutes, and then I'll have to call time of death. Does anyone have any ideas? Anything at all?" No one in the room spoke. "Okay," he said, "another round of epi please." Fifteen minutes later, we called time of death - 0428 - almost four hours after she initially called for help. She was translucent, still, and mottled. I began post-mortem care. I cleaned her, changed her gown, wiped the mascara off her face, gently closed her lifeless eyes, and tried my best to smooth her hot pink locks, only able to guess which way she parted her hair. The doctor guided her mother and father into the room. Her mother wailed, screamed, her knees buckled. We had to hold her up so she could say goodbye to her daughter, her baby. The rest of the night is a blur of tears, tissues, crushing hugs from her mother and the reverberating question "why?" The young woman's body went to the morgue and I left for home. On my way, I saw her son, unaware of what had transpired, sitting on the lap of the grandmotherly woman who works registration. He was coloring and drinking apple juice - a picture of complete and blissful innocence. I hope someday he will know how hard we tried to save his mommy; how sorry she was for making the mistake to use drugs. But it is likely he will always wonder those things. I got in my car and the tears began. First, a hot stream down both cheeks, then a sob. I cried the whole way home. My 5-year-old daughter was awake when I walked into the house. "Mommy!" she laughed as I gave her a big squeeze. My heart was breaking, but I smiled at her. My husband rubbed my back, encouraging me to get some rest and go to bed. "No," I said, "Today, I am going to have breakfast with my baby." Author's note: You may be wondering about the more clinical aspects of this story. There are many different chemical compositions to propellant-based keyboard dusters. According to the pharmacist in the room during the code, this particular dusting compound is known to bind to cardiac muscle and deplete the body's stores of calcium. When the patient's initial labs resulted, approx. 30 minutes after she arrested, she was found to be profoundly hypocalcemic. Many efforts were made to restore her calcium levels during the code, but clearly, it was too late. I often wonder if the precious hours wasted getting the patient to the hospital would have allowed for us to correct her hypocalcemia before it led to cardiac arrest. We will never know.