The very, very old and sick who are full code

traumahawk99 · May 11, 2006

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.

Sugah Britches · May 11, 2006

It boils down to fear. Fear of the pain associated with such a great loss. As nurses, we have an opportunity to assist in this passage, to help people find the courage to let go. To understand that there comes a point when letting go is the ultimate sign of love.

"our current system is failing miserably"

Yes Yes it is...

Spritenurse1210, BSN, RN · May 11, 2006

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 agree with you totally.

dekatn · May 11, 2006

We have a pt. that is 103, CHF, full code. Code status has been discussed indepth many times with daughter who is also POA. She continues to stand firm on the full code status. The feeling I get from her each time I have discussed this with her is the fact that, when all is said and done, she will have done everything she can for "mama". I honestly believe, in her mind, if she makes mama a DNR, that she will in essence be giving up on her and in some way not done everything she could, as a daughter for, her mom. These are elderly, low functioning, poorly educated people, and I don't think anything we say or do is going to change this womans' mind. She just doesn't comprehend that "mama" is sick and will die regardless of code status. It has been explained to her what could happen to the body during a full code and it seems like she just doesn't hear what you are saying to her. She'll just look off into space and totally ignore any explanations of full code. Then, say, I want everything done for mama that you can do. I give up!!

Drysolong · May 11, 2006

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.

Your quote concerning more kindness to animals than fellow man struck me for a few reasons. I am a "brand new" LPN whose knowledge and emotions probably lie closer to the layperson's side than the nurses side. I think that the idea of it being cruel to have a elderly, etc., patient be full code belongs to the medical profession. I, as a layperson, would not think of myself as being cruel in this situation. I think that many nurses don't realize how ignorant of medical procedures the public really is. I don't have have a history of illness or injury, didn't take much medication, etc., so the things I've learned in just the year of LPN training have been new and eye-opening to me. Things that you experienced nurses probably take for granted.

I've always been a very hopeful person believing in miracles. (life itself is a miracle) Without medical expertise, I wouldn't understand (or accept) terms like permanent irreversible damage.

I guess I said all that to say that when families insist on "full codes" they need (as TriageRN_34 alluded to) EDUCATION given at their level of understanding, along with the nurse's understanding that some people just don't know.

Drysolong · May 11, 2006

We have a pt. that is 103, CHF, full code. Code status has been discussed indepth many times with daughter who is also POA. She continues to stand firm on the full code status. The feeling I get from her each time I have discussed this with her is the fact that, when all is said and done, she will have done everything she can for "mama". I honestly believe, in her mind, if she makes mama a DNR, that she will in essence be giving up on her and in some way not done everything she could, as a daughter for, her mom. These are elderly, low functioning, poorly educated people, and I don't think anything we say or do is going to change this womans' mind. She just doesn't comprehend that "mama" is sick and will die regardless of code status. It has been explained to her what could happen to the body during a full code and it seems like she just doesn't hear what you are saying to her. She'll just look off into space and totally ignore any explanations of full code. Then, say, I want everything done for mama that you can do. I give up!!

Here I go again. Nurses may not have time to do this, but in this case, aren't their social workers or someone that would be able to take the necessary time to handle this situation. I know you can't make everyone "see", but I just believe I could talk to this or other patients families at their level (poorly or highly educated) and help them understand. For instance, you said you think this daughter believes making her mother DNR implies that she's given up- perhaps starting from that point, she could be reasoned with.

Judee Smudee, ADN, RN · May 11, 2006

Wonder how this will all play out if their is a pandemic. There will be shortages of all supplies, personel and especially beds. Nurses may be faced with a grim triage. Who gets the O2 or the vent, the 89 year old or the 9 year old. I pray it never comes to that but it could.

CHATSDALE · May 11, 2006

how many of you have made your wishes known to family or signed a living will??

if this is the will of the patient or if they have not made it known what their wishes done is difficult for family members to arrive at a decision

and there may be a disagreement between family members about what is the best decision

there could be feelings of guilt, or just a time needed to face the truth

A nurse or social worker should bring it up...to continue to bring it up after a decision has been made is just harassment...back off, if they show signs or ask questions you can bring it up again

or you can have a modified code...i know all facilities have papers which give a choice of - give O2, hydration,comfort measures but not 'full code'

explain what will be done and what will not be done

this is the hardest decision most of us will make...and they do not see this every day as we do, this is the man who taught them how to ride the bike and the woman who baked their birthday cakes

approach with compassion and hope that they will recognize compassion in themselves

ortess1971 · May 12, 2006

Wonder how this will all play out if their is a pandemic. There will be shortages of all supplies, personel and especially beds. Nurses may be faced with a grim triage. Who gets the O2 or the vent, the 89 year old or the 9 year old. I pray it never comes to that but it could.

That is a good point but I'll throw this one out there....We had a patient who was serving time for domestic violence, had drug issues and tried to kill himself on numerous occasions. Apparently, his life doesn't mean much to him and he is kind of a drain on society.He was about 45. People would be up in arms if you asked him to sign a DNR. Yet, many times an elderly person who is in their right mind, who loves life and cherishes their existence is made to feel like they are being"unrealistic" and selfish because they are costing the healthcare system money. I think it is dangerous to imply that age should be the determining factor. Even "quality of life " means different things to different people. I think at least people are more educated about healthcare and the importance of living wills and we seem to be getting away from the doctor=God mentality(although this doesn't stop many of them from thinking that way!

)

rnmi2004 · May 12, 2006

Put it in writing people! We are required to ask every new admit or transfer about advanced directives. I can't even begin to tell you how many people say "Well, my kids know what to do if that ever happens." I try to educate them about the need to put it in writing, but people still dont' get it.

Here in Michigan recently, there was a case of a 98-year old woman on a vent in an ICU. She has nothing in writing about her end-of-life wishes, no close family members to make the decision for her, and a judge recently chastized a doctor for going to court to try to make her a DNR. The judge stated the doctor was not supposed to try to be an advocate for his patients.

Of course, the article I read also mentioned the woman saying "Let me die" or something similar while intubated, so you can't assume you're getting a complete picture of the case. :rolleyes: The point is, if you don't put your wishes in writing you don't know who will decide for you.

firstyearstudent · May 12, 2006

Today, the social worker was able to talk to the family. Evidently, the man's son who has power of attorney or conservatorship or whatever will not return the multiple calls that the doctors and nurses have left for him (staff are universally advocating for DNR). The man's daughter and some other relatives stopped by to visit today and there is some bad blood between the son and the daughter and they won't talk -- which makes dealing with the family that much more difficult.

Anyway, he is still full-code. He is probably in a coma (pupils not responding) and his kidneys have shut down. After the doctor found out he was staying full-code she ordered a whole slew of tests. She even talked about the posibility of having to put him on dialysis, even though she doesn't want to. He is on a dopamine drip because his BP is so low and no one wants to reposition him or even move him to clean him because they don't want to be the one to make him code.

I guess this is good end of life care to some people, and I have to respect that. I would rather have quality over quantity of time, myself. I just hope he is not in any pain or discomfort. (He's not on any pain medications.)

This brings me to a question for some of the nurses. Do patients who are unresponsive ever have PRN meds for pain or agitation? And if so, do you give those to patients who are unable to request them because you think they might be helpful (the RN's judgment), or can they only be administered to patients capable of requesting them. I wish this guy was being given something just in case he was feeling pain wherever he is.

psalm, RN · May 12, 2006

...it is difficult to see a pt. who has no medical hope being a full-code and suffering. But I also see that as giving the pt time to get things in order with family, with God, with self. Whether he/she does or not, we may never know. So we continue to treat and care...