The very, very old and sick who are full code

Nurses General Nursing

Published

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...

Specializes in Education, Acute, Med/Surg, Tele, etc.

What is really sad is the experience I have seen in elderly that have been coded or heroically saved is that they never gain, always loose function or quality of life...mostly both!

I have had too many elderly residents come back so disabled and worse off then they were...only to die a few months later, or so depressed at their functional level they just give up living! That tears my heart out, and I am quite frank with folks about this issue! My heart was torn to pieces too many times watching these folks slowly fade to death...so I have no probelms talking about these issues with family or the patient themselves!

I am respectful of wishes...but I also feel that making this choice needs to be like any other treatment...must have informed consent! A person that doesn't know what is all done in a code situation doesn't have informed consent! So I teach them so they can make sound judgements, or teach family if that person can not make medical choices themselves!

It isn't easy talking to family about these issues, but must be done...HAS to be done. I learned by watching way to much suffering not to beat around the bush or hope people come to their senses about these issues.

Up Vote Up Vote ×
Specializes in Long Term Care.

I work in a Nursing Home. When we have a resident that is a full code, we require the family members and the resident to sit through a thirty minute video on what it means to be a full code. Then after that the social worker talks to them extensively about what they do and do not want done for them should heaven forbid something happen to them while they are in our facility. Some still want to be a full code, and others opt for the comfort measures and they even specify what measures they want. I think this situation is better for all concerned b/c it educates the residents and the family and clearly communicates what their wishes are to the nurses.

What i think might help some people deal with the lose of their loved one is an explanation of what is going on with the resident. For example, Mary(not her real name) an alzheimer's patient opted for comfort measures only. Her husband jack (not his name either) thought that b/c her body was not as deteriorated, that she would get well and go home. Mary shortly after entering our facility had a stroke, and rapidly deteriorated. Mary went through all of the stages of dying. I have never seen such a clear text-book case. Through almost all of it, Jack was in denial, he kept asking when he could take her home, and blaming the staff for not being able to get her to eat, for her constipation, for her pressure areas, he would come in okay and leave in a fit. One afternoon, he cornered me, in the grocery store of all places. He was yelling at me, cursing and crying and just carrying on. He asked me how I could just stand aside and let her die. I just stood there and let him vent. When he came into the mursing home a couple of nights later, I sat in the lounge with him and I started to tell him about the stages of dying and explained to him what was going on with Mary and why the things that were happening were. After that one conversation and a pamphlet from hospice, he never threatend a lawsuit again. He would cry and try to hide it from us, but there were no more fits, no more screaming at the staff. Mary died a few weeks later, I was sitting with Jack when she went. It was extremely emotional since I had known them all my life. He eventually cornered me in the grocery store again, he hugged me and then thanked me for helping him understand and helping him to begin to let go. I think the importance of our roles as advocates and educators can not be over stated. It is amazing what sitting and talking and educating can do to help heal our patients and those left behind.

Up Vote Up Vote ×
Specializes in Education, Acute, Med/Surg, Tele, etc.

I want that video! Can you tell me who made it and if it can be ordered?

Up Vote Up Vote ×
Specializes in LTC and MED-SURG.

This was such an excellent post. You are also a very good example of what a nurse should be

I work in a Nursing Home. When we have a resident that is a full code, we require the family members and the resident to sit through a thirty minute video on what it means to be a full code. Then after that the social worker talks to them extensively about what they do and do not want done for them should heaven forbid something happen to them while they are in our facility. Some still want to be a full code, and others opt for the comfort measures and they even specify what measures they want. I think this situation is better for all concerned b/c it educates the residents and the family and clearly communicates what their wishes are to the nurses.

What i think might help some people deal with the lose of their loved one is an explanation of what is going on with the resident. For example, Mary(not her real name) an alzheimer's patient opted for comfort measures only. Her husband jack (not his name either) thought that b/c her body was not as deteriorated, that she would get well and go home. Mary shortly after entering our facility had a stroke, and rapidly deteriorated. Mary went through all of the stages of dying. I have never seen such a clear text-book case. Through almost all of it, Jack was in denial, he kept asking when he could take her home, and blaming the staff for not being able to get her to eat, for her constipation, for her pressure areas, he would come in okay and leave in a fit. One afternoon, he cornered me, in the grocery store of all places. He was yelling at me, cursing and crying and just carrying on. He asked me how I could just stand aside and let her die. I just stood there and let him vent. When he came into the mursing home a couple of nights later, I sat in the lounge with him and I started to tell him about the stages of dying and explained to him what was going on with Mary and why the things that were happening were. After that one conversation and a pamphlet from hospice, he never threatend a lawsuit again. He would cry and try to hide it from us, but there were no more fits, no more screaming at the staff. Mary died a few weeks later, I was sitting with Jack when she went. It was extremely emotional since I had known them all my life. He eventually cornered me in the grocery store again, he hugged me and then thanked me for helping him understand and helping him to begin to let go. I think the importance of our roles as advocates and educators can not be over stated. It is amazing what sitting and talking and educating can do to help heal our patients and those left behind.

Up Vote Up Vote ×
Specializes in Gerontological, cardiac, med-surg, peds.

I agree; thank you for a wonderful post. As nurses, we are not only taking care of the patient in these trying circumstances, but the entire family unit as well.

Up Vote Up Vote ×
Specializes in Pediatrics.

My husband and I are going through this with his grandmother. She is 90 years old and up until a few months ago was pretty healthy. Before Thanksgiving, fell and broke her hip,did well (orthopedically) postop but had some minor issues while in the hospital. She was back in the hospital for pneumonia a few months ago. Her daughter couldn't deal with her anymore and shipped her up to my mother-in-law (12 hour car ride) for "respite"

and she has been up here for the last 4 weeks. She decided she doesn't want her back. My MIL took her to the shore for the weekend and she developed CHF very quickly (thanks to the sister not telling her she needs Lasix every day and needs to be weighed every day:angryfire ) She was rushed to the local hospital and intubated. She was off the vent in 2 days and was d/c'd this friday night. Saturday night, my MIL kept asking her if she was ok, in any pain, breathing ok. She kept saying she was fine, but was having significant wob (by report from mil), MIL called 911 at the advice of her neighbor (a hospice RN). She was taken to their local hospital (much better than the last place) and was intubated again. MIL told me that when she was allowed back in to see her after the intubation, gmom gave her this horrific angry stare.MIL is beside herself. we think that gmom was hoping to go in her sleep had mil not called 911. Does all this babble make any sense? I guess I really need to vent:o

DH and I went with mil to see her yesterday for mothers day. She looks awful. CHF, kidney failure. Her hrwould drop real low and then come back up. Today Dh reports her hr dropping into the 30s and hanging out there for 30-40 seconds and then slowly rise. We had a long disussion with mil about DNR and gmom's wishes. She had said to my dh, "why hasn't God taken me?" last week just prior to coming home. She IS coherent and understands everything that you say to her. It is clear to mil that she does not want to go thru all of this. MIL is just so overwhelmed but has acknowledged gmom's wishes. I have tried to explain to her that they need to get a DNR on that chart asap and that just because she is on the vent does not mean that she can't still go into cardiac arrest and that unless there is a DNR in place, they will do everything possible to keep her alive. I explained to her what "everything possible" means, including chest compressions (broken ribs,etc).

Dh is with mil and gmom at the hospital trying to get the ball moving and unfoteuantely, I have to be here at work and can't be there.

UUUUGGGGHHHHHH!!!!!!!!!!! This poor woman.

DH and I believe once she's extubated, she will most likely just go in her sleep. She's tired.

Here's a link I read about a few years ago on this board:

I ordered copies for all the adults in my family that were interested a few years back and almost everyone has filled one out.

Its 5 Wishes. A very easy to understand do-it youself living will kit.

http://www.agingwithdignity.org/5wishes.html

Sorry was so long.

Thanks for letting me vent.

Keni

Up Vote Up Vote ×
Specializes in Long Term Care.
I want that video! Can you tell me who made it and if it can be ordered?

I don't have the info on the video, I will ask my social worker the next time I am at work. I do have the info on the pamphlets.

They Are:

Caring for a Loved One With a Terminal Illnes

CopyRighted 1998 Channing LBete Co. Inc.

200 State Rd., South Deerfield, MA 01373

to Order call 800-628-7733, ask for item number:72935A-7-98

Gone From My Sight: The Dying Experience

By: Barbara Karnes

P.o. Box 189

Depoe Bay, OR 97341

MyFriend, I Care: The grief Expereince

By: Barbara Karnes

P.o. Box 189

Depoe Bay, OR 97341

A Time TO Live: Living With a Life Threatning Illness

By: Barbara Karnes

P.o. Box 189

Depoe Bay, OR 97341

( eash of the pamphlets listed above is three dollars total)

End Of Life Decisions: Making the right choice for you

National Hospice Organization

CopyRighted 1998 Channing LBete Co. Inc.

200 State Rd., South Deerfield, MA 01373

to Order call 800-628-7733, ask for item number:71407D-02-99

These are the ones that I have found to be most helpful in trying to help teach the families of Long Term Care Residents.

I don't have the info on the tape handy b/c there is only one copy at work and it didn't have the info on it. Thus I must ask the Social Worker when I see her.

Up Vote Up Vote ×
Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

I work at a nursing home. My casual observation (not based on scientific fact) is that patients from ethnic minority groups tend to be full codes. I seldom encounter an African-American, Asian-American, or Latin-American patient who has DNR status. With Caucasian patients it appears that the majority are DNRs, but many are still full codes.

Up Vote Up Vote ×
Specializes in EC, IMU, LTAC.
I work at a nursing home. My casual observation (not based on scientific fact) is that patients from ethnic minority groups tend to be full codes. I seldom encounter an African-American, Asian-American, or Latin-American patient who has DNR status. With Caucasian patients it appears that the majority are DNRs, but many are still full codes.

I've noticed it too, mostly in Mexicans. This makes sense, as many are Catholic.

Up Vote Up Vote ×
Specializes in PACU, ED.

I do think we need to honor the wishes of the patient or MPOA. However, this is a good place to do patient/family education. Sit down and educate then about what's involved with a full code. Also let them know they can opt for partial code such as meds but no compressions. The decision is theirs but they need to know that DNR does not hasten death, it just does not prolong the dying process.

My daughter was working as an aide in a hospital and was called to help on a code. Pt was a 90 yr old F with terminal CA. My daughter felt the weak ribs cracking and breaking under the compressions. The end result, they were able to bring back the pt to survive for a day and a half of agony with multiple broken ribs. Pt then coded again and did not respond to efforts to revive her.

Some people want to cling to this world no matter what. All we can do is try to educate them so they can make an informed decision.

Up Vote Up Vote ×

We arent' allowed to ask, some nurses in our unit had told one pts family differing reasons and so it made the Doc mad and so now the buden if off us. The sad thing is sometimes the Doc doesn't get there soon enough and the pt is vented and then the family decides they didn't want it if they knew what was going to happen--so now we can blame the doc's for their own baloney instead of having the hospital make a policy on what we can or can't say....

Up Vote Up Vote ×

I work in a nursing home and many of our patients are a DNR but we have a few full codes. Most of our full codes have state gaurdians and they do ANYTHING to keep them going. They dont do as the pt wishes or look at quality of life. We have patients who refuse to have peg tubes rip them out 3 or 4 times and the OPG still makes them put it back. I think that is wrong. We also have family members of resident who state they hate life and just want to die keep them as full codes. Why keep them full code and put them in a nursing home, that would kill most elderly of wanting to live.

Up Vote Up Vote ×
+ Add a Comment