The very, very old and sick who are full code

CritterLover, BSN, RN · May 18, 2006

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.

i think this is often at the root of the problem. i have seen it many times. the decision-maker thinks that if they do not do everything they possibly can, then it means that they don't love their mother (or whomever) enough.

i used to be a home health nurse in a very rurual area. i had one patient who had chf, htn, diabetes, and some dementia. she was well over 90. all she wanted was to sit on her porch in her wheelchair and eat her bacon, fried catfish, and drink her cokes. but.....giving the above diagnoses, i had to do quite a bit of teaching on modified diets. and sure enough, her daughter took away the bacon, fried foods, and everything else this poor lady loved to eat.

eventually, she ended up going in and out of the hospital quite a bit due to her failing heart. she was a full code to the end, mostly because her daughter couldn't let go. she felt that if she let her mother go, then she had failed as a daughter. no mater what i said or did, i couldn't get the daughter to understand that we all die sometime, it is the natural progression of things.

had she been my mother, i would have made her comfortable, and let her eat and drink what she wanted, and basically do what she wanted. it was very frustrating to me to see all of this happen, and i often had to remind myself of one very important thing: those were my values, not necessarily those of my patient and her family.

mellomom · May 18, 2006

This is such an interesting thread. I have seen these end-of-life pts die a long agonizing death like most of you. The worst was a 90 + yo with multiple medical prob who developed an ileus with end stage dementia, they ended up doing surgery but there wasn't enough viable tissue left to close her so they sent her back OPEN to the floor, where she lost massive amounts of fluid, went into CHF and RF, and was in horrible pain every time we tried to turn her or reposition her...of course we couldn't give her enough morphine due to her Bp being in the toilet...this went on for weeks with her as a full code! Finally even the family figured out she wasn't going to get better and she was converted to a DNR...and finally died comfortably.

The upshot of this and similar experiences is that I look for opportunities to talk to the families about what to expect at end of life, what the prognosis is after hip fx, how dementia affects the dying process, etc. There is so much ignorance.

And yes, I signed a living will & MPOA - everyone knows my wishes!

Roy Fokker, BSN, RN · May 18, 2006

Yes it's hard.

I just recently had a chat with my Father - he told me "try for two days. If beyond 48 hours, nothing comes to good - cut me lose and let me go".

People have different reasons and it's not always about the family.

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.

I've heard many people state this as a concern when it comes to organ donation. I've had people tell me point blank that they won't volunteer because they fear that in the case of a bad accident/trauma etc., the staff will be more interested in preserving the organs for donation rather than their life!

msn2008, MSN, RN · May 18, 2006

I appreciate this topic so much! I work in a CCU where the mentality is to save lives, not approach families about DNR status, so most nurses are very uncomfortable approaching families even when death is inevitable. The words I use when I approach families sounds like this, " I want to make sure we're all the same page regarding your loved one. If his/her heart slows down too much to work effectively, or speeds up too much-VT, or struggles to breathe, with the orders we have right now, I/we will do everything possible to keep him/her alive. This will involve chest compressions, shocking the heart and intubation and connection to a mechanical ventilator. If this is what you all are in agreement with then I will do all I can to make your loved one comfortable and alive. However, if this is not what you want, you need to let me know because I'll need to notify the doctor to have the order changed. You don't have to make this decision right now, but if you want to make any changes, please let me know." Usually I have already pointed out changes I see common to the dying process such as apnea, mottling, decreased responsiveness, etc. I refer to these changes as those we see when the body is shutting down. Most families ask me more detailed questions which I answer with honesty. I never tell them what to do. I tell them their decision is right for them and I will support whatever decision they make. Most have called me back into the room within minutes and request a change to a DNR status; I promptly call the physician to get the order written! I'm always amazed at how some have then died peacefully within two hours! It helps that I have a hospice nurse as a sister, both my parents have passed away and I have a strong faith. My life experiences have enabled me to talk freely about the dying process and approach it as a process similar to the birthing process. I've told families that just like you are not walking around 9 months pregnant one minute and then holding a newborn baby in your arms the next, most people go through a process of dying instead of sudden death. They are usually pretty interested because they have noticed the changes but didn't know what it all meant. It all starts to make sense. Hope this helps someone!

Melissa

Warpster · May 19, 2006

Well, bottom line is that you can't decide for families what needs to be done. What you can do is tell them what a code entails, including the broken ribs she is likely to suffer, the pain, and other complications. They all think it's like ER, nice and clean, just jumpstart the heart and Granny will be back to her normal self.

Often the families don't have the real scoop on what "doing everything" means for the patient. We do have to emphasize that "do not code" doesn't mean "do not treat," and that Granny will still get everything to help her get well, just not dangerous heroics.

It's hard for us to watch, and the spectacle of old people spending their last days in misery tubed and electrically stimulated in an ICU has chased more than one intensive care nurse back to a med surg floor, but it's still not our decision. The reasons may be projected fear of one's own death, or religious reasons, not wanting to say goodbye, or ignorance. Only the last is within our control.

katy_kenemy · May 19, 2006

I appreciate this topic so much! I work in a CCU where the mentality is to save lives, not approach families about DNR status, so most nurses are very uncomfortable approaching families even when death is inevitable. The words I use when I approach families sounds like this, " I want to make sure we're all the same page regarding your loved one. If his/her heart slows down too much to work effectively, or speeds up too much-VT, or struggles to breathe, with the orders we have right now, I/we will do everything possible to keep him/her alive. This will involve chest compressions, shocking the heart and intubation and connection to a mechanical ventilator. If this is what you all are in agreement with then I will do all I can to make your loved one comfortable and alive. However, if this is not what you want, you need to let me know because I'll need to notify the doctor to have the order changed. You don't have to make this decision right now, but if you want to make any changes, please let me know." Usually I have already pointed out changes I see common to the dying process such as apnea, mottling, decreased responsiveness, etc. I refer to these changes as those we see when the body is shutting down. Most families ask me more detailed questions which I answer with honesty. I never tell them what to do. I tell them their decision is right for them and I will support whatever decision they make. Most have called me back into the room within minutes and request a change to a DNR status; I promptly call the physician to get the order written! I'm always amazed at how some have then died peacefully within two hours! It helps that I have a hospice nurse as a sister, both my parents have passed away and I have a strong faith. My life experiences have enabled me to talk freely about the dying process and approach it as a process similar to the birthing process. I've told families that just like you are not walking around 9 months pregnant one minute and then holding a newborn baby in your arms the next, most people go through a process of dying instead of sudden death. They are usually pretty interested because they have noticed the changes but didn't know what it all meant. It all starts to make sense. Hope this helps someone!
Melissa

Thank you Melissa--- I know I will use this information when I am a nurse. ---Katy

lpoore · May 19, 2006

I agree with you. I too am a nurse in a hospice setting and knowing that the patient is going to die but yet the family keeps them on DNR status. Also, I worked in LTC and lots of patients there were Full Codes and that made me so mad. The patients were already on feeding tubes and unconscious so why prolong their suffering. I do know that for the families it is hard to let go but they do need to be told that it is okay to let go. They are not the ones suffering through the pain and trauma of the disease.

Just my 2cents.

Linda

firstyearstudent · May 20, 2006

You guys have got to check this out. A retired nurse!

http://news.bbc.co.uk/1/hi/health/2819149.stm

firstyearstudent · May 20, 2006

And another retired nurse in the U.S.

http://www.desmoinesregister.com/apps/pbcs.dll/article?AID=/20060516/LIFE02/605160389/

kokopelli · May 20, 2006

I work in an ICU and when I am elderly, I would not want my last days on earth being put through the torture I see. It's one thing when there is a sudden illness in a basically healthy person and they are expected to be able to go back to years of living, but why prolong a fact of life. We all die, and it doesn't have to be filled with fear and pain, bright lights and alarms. Why would you want to die with tubes coming out of everywhere, and lines poking into everywhere else. I prefer to be kept comfortable, soft music and my family around talking about the good times and telling jokes

burn out · May 20, 2006

According to one of our physicians DNR does not mean do not treat. Up until the point of actually coding we are obligated to provide care whatever

that may be. If a patient that is a dnr has a drop in blood pressure but has not gone into any cardiac dysrthymias we may well be hanging dopamine, neo or levo because the patient has not coded . If a patient has blood gases that are the pits we may be intubating because the patient has not yet coded. In ICU you can usually see an arrest coming that is why I do not think patients that are DNR's should be admitted or kept in ICU.

Another problem I think families face when making love ones DNR is not only the loss and fear but the guilt they may carry like they were deceiding if the patient lived or died.

starryx2 · May 20, 2006

I feel that this is a very controverseal subject, and everybody has alot of different opinions and reasoings for what they believe, but this is my 2 cents.

IF the patient wanted to be a full code OR their wishes were not ever let known to the family, then as a family member although we see what the patients go through, we are also treating the patients families not just the patient, and if something is sudden or even terminal and someone has not come face to face with it, why are we downsizing that, we are not suppose to be judgemental, we can be patient advocates, and make sure the meaning of "full code" is understood by the family members, and that we are doing everything in our power to keep the patient comfortable in the process. Again we should not let our emotions and our beliefs interfere with our patient care, except for what the family believes.

Now even if a patient had let his wishes be known, and his family still chooses to continue treatments, all we can do is try our best to make sure the family understands the situation, what treatments would be implemented, and to support the family in their decisions, I just think somtimes for things like this we let our emotions get the best of us... and I hate hearing while were on the floors, how this nurse hates this family how can they do that to their grandma... This isn't how its suppose to be, we are patient advocates, and family advocates, teachers, supporters, anything in the book you name it and thats what we do each and every day, I just wish everybody tried to be a little more supportive of the families, and understand that this is a very hard and difficult time in their life and watching a loved one die... Although I have not expereniced it, I can put myself in there shoes and imagine that it is a terrible tragic thing to go through, especially if one is not prepared for it at that time. All we can do is speak and inform, and be advocates, and not judge.

I do not mean to offend anyone by my post, and Im not trying to put anybodys else down or anything, I just want to clarify that point. Thanks for listening.