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Discussion

Violating a Code Status...

An elderly female patient was admitted to the hospital with anemia, R/O GI bleed, dehydrated, c/o pain to right jaw. Admit orders were NPO, type and cross pending H and H, MRI/CT of jaw, rule out infection, d5 1/2 at 75 cc, resume current meds, mostly for DM and mild hypotension, coumadin and synthroid, pain meds ordered and place on telemetry. VS stable upon admit, patient a, a and o x 5, pain is under control. So far so good. Within 3 days she is diagnosed with Parotitis right jaw, transfuse 2 units RBC, place picc line, dc home for daily atb infusion. OK, moved to step down unit....

Day of this incident she is seen by nurse, signed consent for radiology procedure, returned at 1000, some bleeding at site but tolerated well. Spouse at bedside, patient ambulatory and requesting assist with a shower.

Nurse returns at 1210 to discover patient alone, laying on her side in bed, cyanotic, apneic, non responsive, no pulse, calls a code, which per notes happens over 12 minutes before they are able to establish both an airway and a pulse. She is transferred to ICU on vent, BP meds and ativan due to mild seizure activity. Family is notified.

2 days later, despite being on prednisone, intubated, removed from Versed for exam, neuro consult is very grim. Patient has gag reflex, dolls eyes, mild seizures and slowed brain wave activity. Patient is also at this time receiving Glucerna thru oral intubation as midline cath has infiltrated so emesis with positive CRX for fluid aspirate.

Now, upon review of this patients chart, an advance directive is found in the back which the patient and her husband had executed less then 2 years ago, both had checked off "If in the even I am found uncounscious, my condition will not improve or I am faced with artificial life support, including ventilators and advanced cardiac life support, I hereby decline and wish to advance towards a natural death without these measures". It was also in her admitting docs office charts and on file with this hospital.

It was not, however anywhere in her Kardex, anywhere in her admit notes, transfer notes or during a 24 hour chart check. 6 days she was being treated for this infection and no one saw this, nor was it mentioned. Someone finally did though, she was extubated on a Friday evening, given comfort measures, transferred to a med floor and finally passed away early on a Sunday morning.

Now, I guess we all know whom I am am taking about so issue is out of the way, but never in my years of nursing, even while covering for another nurse talking a bathroom break, lunch break, whatever, not know the code status of a patient. I have grieved and felt saddened by the loss of patients, have seen the tears, disbelief and sorrow at a loved ones passing but I always knew the code status and would never subject a patient to something they had gone out of their way to make sure would never happen to them.

People spend thousands of duckets on advance directives, wills and testiments and I am scared 3 shades of psycho to think it could be so blatently (is that conceivable) overlooked in such a way.

Well, in conclusion, always, always know your patients code status and keep your fellow nurses informed. No one should have to go thru this, especially a patient. What do ya say ?

Featured Replies

Last fall I had a 90+ LOL with urosepsis, dehydration and ARF, plus aspiration pneumonia, Ox1. Doc had talked at length with family about hospice and DNR status, but they insisted on keeping her a full code.

Later that evening, she started talking to deceased family members, and her vital signs dropped. It was that shift's thought that it was the morphine, which she needed for chronic back pain, so they stopped it and put her on Risperdal :uhoh3:.

I assumed care at 11 pm, and it was all downhill from there. I tried to convince the doc to come see her, that she was getting worse, but he just gave me a pain med order. Less than an hour later, I was doing compressions on her thin frail chest. Another (wonderful) nurse called the family immediately, and they said they wanted everything done. But she went into asystole, nothing we did revived her, and we ended the code.

The other (still wonderful) nurse called the family for me, and they came in. They told us they had a feeling she was going to pass because she'd been talking to her deceased husband the previous evening. What I didn't get is why they still insisted on everything being done, after that? That code still haunts me.

Last time I worked I intubated at 93 year old man. Stroke in Feb. a&o times 0-1. Aspiration pneumonia from tube feed. Peg tube, sunction every two hours just to think your helping. Family members wanted everything done at the bedside. Tubed him and was transfering him to ICU. Son was like ICU?? Yes, that's where they go if you intubate people??? I hope that man didn't suffer long. I hope the family just got the since to say enough is enough. Like the quoted person says. This still haunts me! :)

:confused: Guess what happened at my facility tonight!??!??!

DNR status was not relayed in report--just happened. But, to err is human.:smackingf Like luvpeplrn said, I would rather code a DNR than NOT code a Full Code.

's RN

Update---

:smackingf Found out last night that there was not a DNR doctor's order written AFTER the MD and familiy decided to make the patient a DNR. Therefore, the staff was correct to code this patient, because in our hospital, and I think state, you MUST have a written order in the chart, not just the paperwork that states what the patient does or does not want.

's RN

I had a pt the other day who was circling the drain. She had been a frequent flyer, and had been a no code for years. She felt the end nearing and was expressing second thoughts, and said she wasn't ready to die, and wanted everything done. What a hassle, as a pt advocate I had to communicate her wishes, try to contact her DIL whom the doc had tried to call. Then she changed her mind again at shift change.

I'm sick of our medical system, I'm sick of all the muddy waters, with everything falling on the nurse. Our system is broken.

:uhoh3: Hey jlsRN,

Sounds like you have some serious burn-out!!! Been there, done that. But when I tried to take a break, I started to go crazy sitting around the house doing nothing, (I'm not an "outside" person), and after three weeks, my dear, loving, wonderful husband was driving me BANANAS!!!:selfbonk: Really felt like knocking myself silly! So, I went back to work and counted my blessings, muddy waters and all!

's RN

I took care of a pt in LTC a few years ago. I forget all the exact details, but he had a severe stroke while on vacation in another state. He was taken to the hospital in an unconscious or semi-conscious state, so implied consent was assumed and life-saving measures were performed, including inserting a G-tube because he could no longer swallow.

When he awoke and was able to speak he notified the medical staff that he had advanced directives, but the hospital had not been able to access them in time before implementing the life-saving procedures. So now this guy was stuck with a g-tube he didn't want. He was so miserable he ended up going through the LTC's ethics committee and they agreed to stop g-tube feedings. He was given pureed meals PO and did okay with them for a few weeks, at which point he got aspiration pneumonia and died.

As a brand new CNA at the time it baffled my mind how a man could choose death over something that was keeping him alive and nourished, but since his wishes were betrayed to begin with, it was his right to make the decision that he did.

:scrying: The hardest thing that I ever had to do was to tell the resdent at the hospital that my dad was in that he was NOT putting daddy on a respirator. He had a DNR on file with the hospital he was at, and he was going to honor it, or answer to ME!! :argue: And trust me, you DON'T want to mess with me about mine!!!! :nono:

's RN

I have a question. Nursing home based, we have a patient with terminal cancer. they admit him to hospice care. the patient himself requested to be a full code. Nurse does not even check chart or start code. what are the consequences.

If you are in hospice you are supposed to be a no code. You need to notify your supervisor, obviously there was a misunderstanding here when the patient enrolled.

Hospice accepted him as a full code. they were trying to get him to sign the consent papers. he refused himself. i think it was negilence on the nurse behalf.

I would write that up, that's outrageous. The whole point of hospice is to accept end of life care with no heroics.

I was in a code last week where the patient was having compressions for 20 minutes when the doctor said, matter-of-factly, "Anyone know his code status?"

  • Expert
am i missing something here? there was an advance directive, but no dnr order from the doctor? if that is the case, the patient is a full code until that order is written, regardless of the directive.

the va advance directive form states "if at any time my attending physician should determine..."

http://www.thearcofnova.org/docs/directiveform.pdf

it's up to the doc to make that call and honor their wishes.

this is the way it is in both states i practice in.

an advanced directive makes the patient's wishes known to their physicians and family but a patient isn't a dnr until a doc writes the order.

this is one of the many reasons that i love, love that wa & or have endorsed the polst program (some states call it a molst)..

all the treatment info is right there, printed on hot pink or lime green card stock, complete with the physician's original signature. the form can be used for both adults and children, is standardized though some states have minor variations in wording to satisfy state law or suppliments. most imprttantly, it travels with the patient, a facility or hospital can make a copy for their records but at transfer or discharge the original goes with the patient and is recognized by all healthcare delivery systems the states that endorse it.

http://www.ohsu.edu/ethics/polst/

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