The Slow Code: Justified?

[TheCommuter, BSN, RN]

Another finding that disturbs me is the occasional hospice patient who remains a full code because their adult children cannot agree on anything and no one will step forward to sign the out-of-hospital DNR form.

[echoRNC711, BSN]

Years ago people were allowed to die at home. Nowadays 70-80% will die in a hospital attached to some type of machine . In bygone days,death used to be, a sacred passage and was honored as such.The family gathered around when "it was time " It was a chance to honor the person,feel the sadness of letting go and raise the dying person's spirit up soulfully. Yes, there are wonderful hospices but few pt get there. A friend pointed out to me recently that often pt die alone with the tv playing cartoons or rap music to mark their passing (unless of course some astute nurse is there waiting with electric paddles to electrocute them "back to life"

I know I digress from the topic, it is an area closest to my heart so please permit me to say. It is wonderful how advanced medicine is but I believe we are slowly losing the plot where our actions now devalue rather than value life in particular when it comes to end of life care.

Thankfully there is a movement growing called "gentle death ". It has nothing to do with euthanasia or ending care. It promotes quality,to allow people to gently leave life with the same care and love that we welcome a new baby,by celebrating the life before us. Regular folk with no medical background are attempting to re instate that respect for life and death by simply sitting with pts., listening, comforting,simply being there.

It feel that it really is time that we re-balance the pendulum. How terribly ironic that we "save " a pt life so they can live for a few months feeling the fullest extent of what hell on earth is.Seems to me,we are lacking both mercy and judgement (no pun intended ) Florence Nightingale was honored by Queen Victoria with a medal saying "Thou art merciful " Have the risk of law suit or a ,skewed perception of life robbed us of that mercy that Florence taught.

[sharonp30]

Wow, I guess this is something that I didn't even consider when I was thinking of ethical issues that I could face. I really think that first of all, you want to follow the patients wishes, but I can see where there could be an exception. I was aware that Hospice has some unwritten rules about meds and such, but this is really something to think about.

I remember having surgery several years ago, I put down there that I wanted to be kept alive by whatever means, but I was in my thirtees and had a young child. I obviously wouldn't want to be kept alive if I couldn't be saved, but was afraid of putting that down. I guess it's silly, but a lot of people think the same way, I am sure of it.

Thanks for the post. It gives me a lot to think about.

[somenurse]

Wow, I guess this is something that I didn't even consider when I was thinking of ethical issues that I could face. I really think that first of all, you want to follow the patients wishes, but I can see where there could be an exception. I was aware that Hospice has some unwritten rules about meds and such, but this is really something to think about.

I remember having surgery several years ago, I put down there that I wanted to be kept alive by whatever means, but I was in my thirtees and had a young child. I obviously wouldn't want to be kept alive if I couldn't be saved, but was afraid of putting that down. I guess it's silly, but a lot of people think the same way, I am sure of it.

Thanks for the post. It gives me a lot to think about.

You are a great candidate to have a living will drawn up. (or, as it was referred to, during the Obamacare discussions, a "death panel") A living will can state ANYTHING *you* want done, for example--- do everything, no matter what!

Or everything unless i am verifiabley brain dead for 3 days. Or whatever algorithm fits YOUR wishes. It is NOT a "death panel" as so many seem to think it is. It is only a statement of your exact wishes, in various scenarios, to relieve your family of trying to guess what you'd want done in this or that case.

The Terry Schiavo case proved to us, that just telling our partner our wishes, isn't always good enough in some cases.

I've got a living will, AND i've also assigned a medical power of attorney, also. Nope, it is not my sweetie, after watching how hard he struggled to decide it IS time to put down our beloved dog who could no longer even walk. Nope, i chose my very assertive pal, who is very much on my page, who very much understands *my* wishes, and i know, without a doubt, she will go to bat for me, should i ever end up on some vent with no brain left and my family falling apart at the bedside, she will step in with that "medical power of atty" paper and REALLY "save" me.

[T-Bird78]

If there's no DNR then aren't we required to use any and all measures? Just because someone's older doesn't mean they don't get the same level of care and urgency as a child. They're somebody's parent, somebody's grandparent, somebody's spouse. It almost borders on criminal neglect.

[somenurse]

If there's no DNR then aren't we required to use any and all measures? Just because someone's older doesn't mean they don't get the same level of care and urgency as a child. They're somebody's parent, somebody's grandparent, somebody's spouse. It almost borders on criminal neglect.

yes, you are technically and legally correct, without a written DNR, you are supposed to code even the terminally ill person, known to be suffering excruciating pain, is supposed to be brought back from the dead, you are legally right.

I wll admit, sometimes, caring for such ppl AFTER the code, sometimes feels like we have done a criminal thing to brutalize them in this way, though, with their families slowly falling off the cliff, day by day, for weeks on end, and the person dying one inch at a time....it's brutal to watch.

but, maybe you have to be there, to see what i mean about how cruel that choice can seem, in weeks to follow, after the "save".

[TheCommuter, BSN, RN]

I also have strong feelings about our death-defying, death-denying society. Death is a very natural end to what we call the circle of life.

https://allnurses.com/nursing-activism-healthcare/our-death-defying-773839.html

Years ago people were allowed to die at home. Nowadays 70-80% will die in a hospital attached to some type of machine . In bygone days,death used to be, a sacred passage and was honored as such.The family gathered around when "it was time " It was a chance to honor the person,feel the sadness of letting go and raise the dying person's spirit up soulfully. Yes, there are wonderful hospices but few pt get there. A friend pointed out to me recently that often pt die alone with the tv playing cartoons or rap music to mark their passing (unless of course some astute nurse is there waiting with electric paddles to electrocute them "back to life"

I know I digress from the topic, it is an area closest to my heart so please permit me to say. It is wonderful how advanced medicine is but I believe we are slowly losing the plot where our actions now devalue rather than value life in particular when it comes to end of life care.

Thankfully there is a movement growing called "gentle death ". It has nothing to do with euthanasia or ending care. It promotes quality,to allow people to gently leave life with the same care and love that we welcome a new baby,by celebrating the life before us. Regular folk with no medical background are attempting to re instate that respect for life and death by simply sitting with pts., listening, comforting,simply being there.

It feel that it really is time that we re-balance the pendulum. How terribly ironic that we "save " a pt life so they can live for a few months feeling the fullest extent of what hell on earth is.Seems to me,we are lacking both mercy and judgement (no pun intended ) Florence Nightingale was honored by Queen Victoria with a medal saying "Thou art merciful " Have the risk of law suit or a ,skewed perception of life robbed us of that mercy that Florence taught.

[neurorn6]

Slow codes used to be come place in hospitals. Physicians would write or verbals tell us to do a slow code. Usually due to the patient's condition and the family's inability to come to terms with the finality of the patient. Then about 15 years ago, in the Northeast, JACHO announced that every patient had to be either a full code or DNR. No half way measures. It helped. Our social workers were availabe 24/7 and able to speak with patient and/or family members. Slow codes happen, but often if we are proactive, we can educate patients and family members get the advance directive completed before any thing happens.

[SwansonRN]

Unethical, but I know they happen all the time. Personally I hate having frail, cachectic full code patients in their late 90s. When they start going down hill I always think 'please don't make me have to start compressions!' But it's not my place to decide who should gets 100% during a code and who gets 25%. Full code's a full code.

[echoRNC711, BSN]

Thanks commuter , Nice link . Well , for me, I believe in reincarnation ,so I see death more as a continuum than the end of a circle of life. Works for me. But hey, all roads lead home in my book.

[Anoetos, BSN, RN]

For the record, the "death panels" we heard about are those ethics boards and teams specially charged with determining whether the care of certain patients has become futile.

The idea of a "death panel" comes from their empowerment to, effectively, make the patient DNR without the agreement of the family in extreme cases. This is already happening and, in my opinion, needs to increase. I cannot tell you how many patients I have watched languish in effective brain death and persistent vegetative states because their families cannot let them go.

[NursieNurseLPN, LPN]

When i was 12 years old my father had his third heart attack. He was told he had less than six months to live. He went on to have three open heart surgeries and a defibrillator put in. By the time i turned 21, we were astonished and so grateful that he kept "pulling through" and that he was able to be a part of our lives. By the time i was 21, he had multiple diagnoses- chf, copd, dm, kidney disease, was on dialysis, etc. He went into cardiac arrest at home one night, we performed cpr, emt came, admitted him to the hospital. It took 3months to get him home again. But he came home, and lived for another two years. He lived for 14 years longer than anyone thought he could. While i understand that he was younger (60s), and its not the same as the 90+ year old on life support, these 14 years gave him the time to come to terms with his life, accept his death, and ENJOY every single moment we had together. When he finally passed, we were at peace because we had accepted it years earlier, and were grateful for every single extra second we had with him. So many things happened in those 14years! Ill forever be thankful to those who worked so hard to resuscitate him each and every time he coded, regardless of the fact that he was somewhat of a "lost cause". Anyone on the outside looking in might have thought that his life was over, it would be useless to put him through it all again (he was ventilated two different times). But i know its what he wanted. He was scared, and not ready. He was given time to come to peace with his death, and i am so grateful for that. If we had just decided to let him go after the doctors told us he had 6months, we would have lost so much.

I just hope before some nurses make such a big decision, they are 200% sure thats what that patient wants. And to the person that said a physician can decide/not decide when its past the point of no return, WE are NOT physicians! It truly is not out job. Even while i can see that at certain times it may be more ethical to not resuscitate, where does it stop? Who are we to decide such fate. Who's to say that the new nurse watching you will not have the same decision making process & maybe they decide to "slow code" someone who wouldnt want that. We are responsible to educate our patients/families and continue to educate them as needed. If they make the decision to full code someone who truly should be a dnr, we have either failed to educate them or we just have to accept it. I would hate for a nurse who ive known for two weeks to decide my fate over my decision or my families decison.

All this said, i do understand situations where the patient is already far gone or is just not coming back, but that doesnt mean we dont try for every patient we "think" wont want it. Im sorry if i went on too much, and i am sure that more nursing experience will enlighten me to different views, but i pray that i never forget that it is NOT my decision. Alot of you say you wouldnt want to be brought back if you were that far gone. But be careful because you never know what nurse you'll have on that day that may decide you're too far gone. It may not match up to your meaning of it. I strongly believe in advocating for ourselves, and having a living will spelling out our exact wishes. And i strongly believe all healthcare personel should follow those to a tee.