The very, very old and sick who are full code

Maybe they are respecting his wishes? Maybe they just can't let go? It's not what I would choose for myself, but then everyone is different.

I am in my second semester and doing my Med-Surg II rotation and I am just trying to get my head around this. My patient today was 98 years old, on a ventilator, being fed through a PEG tube, had weeping edema and is barely conscious (in a twilight sleep most of the day). Why would family members keep this man a full code? Is seems so sad to me...

I know what you mean! I see it all the time! Maybe at some point when you are a nurse you will have the opportunity to sit down and talk with these families, explain to them what it means that the pt is a full code. Sometimes when you simply say to them, with compassion and honesty, "I see your father/mother/whatever is a full code. This means that if something happens we will have to do everything possible to save them, inclusing chest compressions and possibly a ventilator," they will say, "Oh no, we don't want that." It is surprising how often they change their minds when you put it like that. I hope you don't mind the unsolicited advice; I just see nurses all the time who don't broach the subject and I feel so sorry for the pts. Does anyone else out there have ideas for how to broach the subject? I would like to know.

I did a clinical in ICU this semester, and I wondered the same thing. Someone told me that at that point when there's nothing else to be done it's not about treating the patient (provided the patient is comfortable and in no pain); it's about treating the family. Sometimes I guess it takes time for family members to realize the futility of a full code, and sometimes they never do get it. I still think it's kind of sad and pointless, but I understand that the patient's family may have issues with dealing with the death (or impending death) of their loved one and may need time to adjust.

one time i had a pt who was 100 yrs old.

her children were aware of her late stage (metastatic) cancer but chose to keep her a full code, and obviously refused hospice.

after an in-depth discussion with them, they agreed to make her a dnr and to receive hospice.

throughout the few wks i had her, they still vascillated between dnr and full code.

in my 10+ yrs in hospice, i have found that those who struggle w/their own terminality, will also struggle with family members' terminality as well. typically all the logic in the world won't change their mind.

but i agree that many are not aware of what a full code involves.

all involved need to know.

leslie

As long as it is the wish of the PATIENT I have no problem with it. If it's becuase of whatever issues the family has then I have a real problem with it. I think it's cruel and unusual punishment.

I cannot believe in this day and age that we will allow our parents/grandparents to suffer so. If that's their wish then I fully support it but not becuase family isn't ready to "let go". :angryfire I mean if we did that to our pets we could be arrested. How come we allow it for our family members?

I see both side of this issue as have the previous posters. My mother is one of these patients, and I'm her youngest child, and also a nurse, mother made me her POA and made it very clear that she wants to always be a full code.

Several physicians and nurses have talked in depth with me and dad about her status, but dad is adamant about all measures being taken as well as having mother stating the same, I feel that I have no choice but to honor their wishes.

It is hard to watch her decline, but, I have her written wishes with me at all times.

I have seen a lot of families who fear that if they make their loved one a DNR, that somehow the staff will stop taking care of them. I've heard this directly from more than one family. All the talk in the world cannot convince them that we won't deliberately kill their loved one once they're made DNR.

We can talk to them, try to convince them that the only change in care would be that if the patient dies, we will not use CPR to attempt to bring them back.

I'm not sure where these folks get the idea, but it's out there and a lot of people seem to believe it.

this is pretty common. a friend of mine stated once we as humans are kinder to our animals than our fellow man. I had cared for a man who was comatose, on a peg tube, with perminant irreversable brain dammage and the family kept him a full code at 75.

It depends on a lot of factors- I feel if the patient has expressly stated that they want to be a full code then their wishes should be respected. Just because someone is old doesn't mean they are not valuable anymore. My grandmother died at 89 and up to her dying day she was mentally aware and with it. You would not believe how many times docs, nurses, cna's etc thought she was out of it because of her age. She told the doctor to stop hassling her to sign the DNR and to do his job and help her get well. I was so proud:lol2: . Now, if someone is not mentally competent to make the decision and it's more that the family is in denial, that's a different story. I do think compassion is the way to deal with these families though. I don't believe being judgemental with them is the way to go-education about what the whole process entails seems best. I learned my lesson and wrote down my wishes- I want it ALL done as long as I'm not brain dead..Full code all the way!

I have seen both sides of the coin, and never get suprised at the times I see people/family choosing full code vs being a DNR so seemingly inappropriately!

I have seen parents mark their children as no advanced interventions ("I don't want tubes in my child"), and elderly wanting everything to be done...even at the ripe old age of 103! Nothing suprises me!

What I find is it is a lack of information about the measures and treatments! What "tubes" mean to one person isn't what it means to another! What one's idea of 'heroic' isn't what another person feels as 'heroic' and so on! What being intubated could certainly fall into someones idea of a 'vent', but some feel it is a machine only...

One of the ones I run into CONSTANTLY, is the whole DNR deal...and my patient is in serious need of interventions. They are breathing and have a pulse...but in order to KEEP that going on...sometimes we need to get an IV in or put a nasal cannula with O2 on. Never fails I either get another medic or family member freaking out saying "they are a DNR..." or "they are DNR so stop that oxygen" or the most popular "stop that IV, they don't want any tubes!". UHGGGGGG! I have to remind folks a DNR means do not bring back from the dead...but stopping death or providing comfort before they die...well that is the definition of my job! (heck...I also remind them that we can do "short term" iv's...the rules are no LONG term IV tx!).

So it is education that is very very needed! The fear of death and the fear of being attached to a machine seem to be one in the same at times...so education on treatments and careful planning of what one wants done given the worse and semi worse case scenero needs to be done with their MD (usually initiated by the RN).

Education Education Education...

Lack of knowledge, about what really happens during a code and the odds of survival NEED to be shared with families. This really is a disservice to patients and families. IMHO and experience, people often feel that if they make their loved one a DNR, they are essentially giving up on them. They feel that it appears that they do not love them enough to fight. It saddens me to see families suffer with these decisions. It should be a time of compassion and love, not a time for guilt.

the question i'd have is what they're fighting for? is the 90 year old going to somehow be 15 again? as a society, can we really afford to be providing this level of care to someone with no quality of life and no prospects except to lay in a comatose state for another few months, until the pressure ulcers get deep enough to put your fist into and they die a horrific death?

all of us have seen terrible things, and i'd have to agree that education and a dose of reality is needed. it's unfortunate that people are so clueless as to realities of end of life care. i truly feel that the nursing profession, as patient advocate, has really dropped the ball here.

if someone really wants this care, i have no objection to providing it. what irks me to the nth degree is when the family overturns the patient's wishes for their own psychological needs without making a legitimate effort to understand that they're guaranteeing that their loved one will suffer a horrific death.

when the baby boomers really smack the health care system, this type of care won't be the norm. as a society we simply won't have the money to afford this fiasco. it's wrong to provide such intensive and expensive care to someone with no prospects of anything except a terrible death while others can't afford simple medications. ever seen an elderly person suffer a stroke because they had to choose between eating and blood pressure medication? i have, and it disgusts me.

it's too bad we don't all live forever and every disease can't be cured. there are difficult choices to be made. our current system is failing miserably.