To code or not to code?--long

[PiPhi2004]

I had this patient the other week that truly disturbed me. She was an 82yo with progressive alzheimers and was in multisystem organ failure. She had been in a nursing home for 10+ years, she was 80lbs or less SEVERE malnutrition, contracted, just no quality of life at all. Well here are pretty much the events of the day.

I come on and get report for this pt and another pt. I had been told that family was very hard to deal with and that they refused to accept that there was nothing else we could do. She was on one pressor (levo) at half the max dose for her. She was on max vent settings and labs were horrible.

So she begins circling the drain and I had to add another pressor and maxed out the levo, I alerted the unit clerk to let the family know that it would be awhile before they could come back and that I needed to get her stable first.

15 mins later the family STORMS in DEMANDING to see their mother. 10 of them (no joke) show up and want to visit. I state that only 2 is allowed at a time and explained that the pt is stable at this time and we only allow the entire family back if she is actively dying. She wasnt, and of course they wanted to talk to our manager.

I get the manager, the son screams at her and she settles them down by explaining the rules (bless her!) and they finally listen and I tell them that if anything should happen I would gladly let them back. My manager also explains to them that if we were to code the pt she would feel pain, her ribs would break and she would not have a good transition into death. She also told them that with 10 people in the room we could not code the pt quickly.

The dr meets with the family to TRY and pursuade them to make her a dnr/dni. They have a family meeting. During the meeting, I max out on 3 pressors. She goes into Vtach but isnt dropping pressure (she stayed in vtach for 14 hours...absolutely amazing to me!) I alerted the resident and told the family they could ALL come back and see her. All are ready to make the pt a DNR and allow her peaceful transition to death. They say their goodbyes and let go. She is on so much medicine I have to replace meds within >1min or her MAPS enter the 20s. There are 15-20 people in the room and getting to the IV pump is becoming impossible, yet no one wants to withdrawl and my manager is with the family and isnt saying anything about the problem, so I try to work around it.

One family member from far away finally makes it to the room, she says theres NO WAY we aren't going to code her, she says she doesnt care if we break her ribs or whatever, we ARE going to code mama! I want to puke! The family is crying, begging, pleading with her to not make us break her ribs. This woman is not POA or anything, shes just a daughter.

I send labs, the tech argues with me telling me i drew them off a corpse. They honestly thought it was a cruel joke. Her PH was 6.5, K+ was 9.0. O2: 16. Absolutely horrible.

Well she finally gets so bad she needs coded. The family is crying and still pleading with the daughter not to make us shock her and do full on CPR on her. Nope! She says do it. We do it and of course she does, ribs are broken, and the worst, her cheeks are pulled off by the ET tube tamer when we are getting her cleaned up IN FRONT of the family (per their request, they saw the CPR and everything). Better yet, this crazy daughter wants an autopsy!!!! I was FLOORED!!! The resident later told me he had nightmares about this incident and couldnt sleep. I couldnt sleep at all that night either after all that. My question is, WHY couldnt we tell the family no?!??! Arent there any laws in place keeping this from happening? What could we have done instead of tortured this poor woman into death? When I asked the physician, they told me we had to and we had no choice. So whats wrong with this picture? I have been in the unit for only a year's time, so what would you guys have done being in this situation because I NEVER, EVER, want to go through that again!!!

[santhony44, MSN, RN, NP]

Who was the POA? Was that person there?

[PiPhi2004]

Who was the POA? Was that person there?

Yes, but he wouldn't decide. He just kept saying "I dont know, I dont know, I just dont want her to suffer," but wouldnt answer the question yes or no

[santhony44, MSN, RN, NP]

That's who should have decided. If he wouldn't make a decision, then I'm not sure, legally,what else could or should have happened.

I'm sorry everyone had to go through that- you, the physicians, and most of all the poor patient.

The POA needs to be someone with the backbone to stand up and make a decision and tell "Last-Minute Lizzie" that she's not overriding it. Of course, had he a backbone, you likely would have never seen the patient; she'd have been kept on comfort care somewhere outside an ICU.

I don't know that you could have done anything differently, once your manager was involved.

[VivaRN]

What a horrible situation. I am so sorry you and everyone involved had to go through that. Ideally these decisions about dnr/dni should be made by the POA before the patient is at that point... she had alzheimer's so it's not like this was a shock. This represents a failure farther up in the system that came to a head with you.

Ethically, the concepts behind it are if "we" as healthcare providers start deciding who to code or not to code that power could be abused. This is why the POA is there whose only interest (supposedly) is the patient.

What can you do? Encourage your friends, family and patients to make their wishes clear about what they want done to their bodies, and to choose their POA carefully. Prevention.

All the best to you in finding peace. You did the best you could with a truly awful situation.

[CritterLover, BSN, RN]

physicians do not have to follow family wishes in what would be a futile code. they are absolutely not legally obligated to participate.

they are well within their professional bounds to say "no, coding this patient will not be beneficial."

the problem is finding a physician that is both secure enough in his/her assessment of the situation to stand up to the family, and has the backbone to do so.

i have had the pleasure of working with a few er and critical care medicine doctors that will do this, but most are too afraid of a lawsuit.

interestingly, while i've seen it happen a few times where the doctor refused to code a patient when a family member wanted it done, i've yet to see any family sue over it.

it is almost as though the family knows that nothing can be done, but given a choice -- any choice, they just can't bring themselves to say "it is ok to let her go." they need someone else to make that decision for them.

[PiPhi2004]

physicians do not have to follow family wishes in what would be a futile code. they are absolutely not legally obligated to participate.

they are well within their professional bounds to say "no, coding this patient will not be beneficial."

the problem is finding a physician that is both secure enough in his/her assessment of the situation to stand up to the family, and has the backbone to do so.

i have had the pleasure of working with a few er and critical care medicine doctors that will do this, but most are too afraid of a lawsuit.

interestingly, while i've seen it happen a few times where the doctor refused to code a patient when a family member wanted it done, i've yet to see any family sue over it.

it is almost as though the family knows that nothing can be done, but given a choice -- any choice, they just can't bring themselves to say "it is ok to let her go." they need someone else to make that decision for them.

this is what i learned in school, but after school ended i also learned that there was a difference between school and the real world. i wish we had some docs with a backbone that would see how damaging this is to residents, nurses, family members, etc. it has really bothered me and will for a long time to come. thanks for all the info!

[CritterLover, BSN, RN]

as much as i would like to believe that the problem is finding doctors with a backbone, i really think it is finding one with enough confidence in his/her assessment of the situation that is more important.

had a situation somewhat similar (in principle) recently at work.

an elderly (80+) lady fell and broke her hip. came into the hospital, was deemed to be inoperable, so she stayed on the ortho floor in traction.

several weeks into the admission, she started having some sob and arrhythmias, and it was felt that she was either having a heart attack or a pe. she wasn't really unstable, but had the potential to get that way.

i went to help out with her, and found (on the very front of the chart), a form from her nursing home that stated she did not wish to be resuscitated. signed by her, before her dementia set in.

now, there is no dnr order in the "orders" section of the chart. and this isn't an official pre-hospital code form -- just the form from the facility.

when this form was pointed out to the surgeon, in hopes of getting a dnr order, he stated that he couldn't write an dnr order without talking with the family first. (just to clarify, they were having a hard time reaching the out-of-town family)

bull.

he may not have been comfortable writing that order without talking to the family first, but there is no law, (nor any ethical prohibition) preventing him from writing that order just based off of her clearly-expressed wishes.

similarly, in your situation there isn't any law or moral standard that would prevent the physician (who knows the patient's history and current situation) from refusing to run a code on your patient.

it would be one thing to hit the code button and have a code team that doesn't know the patient respond and refuse to run a code when the family is asking for it to be done. that would be questionable. but, it is completely different if the physician knows the patient and knows the code will be futile.

several years ago, i worked in an sicu that had a young (early teens) trauma patient that was with us for a very long time. she had her ups and downs. one day, when she was actually on one of the "up" swings, she had an apparently acute bradycardic episode (during visitation) and quickly went asystole. she ended up being coded, off and on, for the next 12 hours or so. the family was there for the whole thing -- every drug, every chest compression. finally, one of the surgeons said "no more," despite the patient's tearful, begging mother. the family was adamant that we continue the resus efforts. thankfully, this surgeon intervened and put a stop to it all. the next time she went asystole, we let her go.

so, it can be done.

i think the reasons we don't see that kind of thing very often is multi-faceted.

part is the fear of a lawsuit. they are very traumatic, even if the provider was correct, and ultimately wins.

part of it is not wanting to be the one to give up.

part of it is not wanting to disappoint the family.

part of it is simply not being comfortable making that decision.

part of it is a nagging voice that says "but how do you know it is futile unless you try?"

some of it may have to do with the provider's personal/religious beliefs.

much of it is lack of experience -- the ones that are willing to override the family request are usually (though not always) older and more experienced.

i also think that part of it is a fear of death and providers not being comfortable with their own mortality.

at any rate, it is all-around frustrating.

[daters]

Hello everyone in Nursing Land,

I have been reading with interest these articles and they raise some very emotive responses. After 35+ years nursing, I still wonder why, as a profession as Doctors and Nurses, we actually ask families what they want us to do in these situations or offer them a choice. Generally, unless you are dealing with medical people in the family, the general public do not have an understanding of the issues that the Code team may be faced with. They generally do not have our training or knowledge of medical issues and cannot make an informed decision or even a choice based on anything other than a desire to see their loved one returned to them. I understand how difficult these scenarios are, but the burden of guilt that some families may carry after making some decision to continue OR withdraw must be huge and unbearable. Sometimes, I feel it would be so much better to tell families exactly the state of play and to let them off the hook so to speak. As an example, the following imagined scenarios "Your 'relative' is very ill. He has problems with his lungs, his heart and his digestive system. We also have issues trying to treat an overwhelming infection. We are using maximum anitibiotic cover to assist and as many drugs as we can in this situation. We have to tell you that we are very concerned that we are not winning the battle as your relative was very ill to begin with and they may not have the reserves to help us win. We are going to continue to try as best we can to do everything we can, but we wanted to let you know how serious the situation is. We will keep you informed of events on a daily basis and you may speak with us and ask questions at any time. At no point, will you be asked to make a decision regarding whether to turn off life support as that is a decision that the patient may make for himself as far as his condition dicatates, but we will continue to try to assist in every way possible.

I have been in situations where families have made ludicrous decision and make the burden upon staff impossible. Attempting to save 97 year old grandmothes who obviously have reached their term of life and who probably have accepted themselves that their earthyly life is now over. The environment produced by a family demanding that everything possible is done, whilst documenting everything that is said and done with the patient, is nothing less than harrassing, frustrating, demeaning and all but intolerable. Unreasonable expectations of the family are often not met and lead to complaints, verbal abuse and unnecessary intimidation of staff and I believe should be dealt with at the earliest possible moment. Very hard when you may not know what you are dealing with in the first instance.

What do you think??

[BlueEyedRN]

One of our intensivists is absolutely amazing with families who insist we do everything. If he was on, we never had to do a code on someone who should be allowed to go peacefully. He takes the family into a private room, spends at least half an hour with them, and by the time they come out, the family has accepted that it is time to let go. I don't know how he does it. But if he isn't on, we end up doing the code. A lot of times, when the family sees what we are doing to the patient, they will stop it. I really feel for them, but it is pretty frustrating, especially when the patient wanted to be a DNR in the first place. We also have a chaplain who is amazing in these kinds of situations.