Why do we do codes?

smf0903 · Sep 8, 2017

For the 20%.

elkpark · Sep 8, 2017

So the families don't sue us.

blondy2061h, MSN, RN · Sep 8, 2017

This is where goals of care discussions are important and should become routine. An 80 year old who is already hospitalized (and therefore likely has comorbidities) is not ever going to have meaningful recovery from a code even if she achieved ROSC as she did in your case. In an ideal world, she would have had a goals of care discussion on admission to the hospital and been a DNR so that never would have had to happen. Our world is not ideal. Goals of care discussions are never fun, seem pointless when people are minimally ill (even if they're elderly) and are time consuming in a world where healthcare providers are rushed. Further, patients and their family members often have a hard time seeing past the fact that they want to live. Dying is scary.

Codes can go well and many people do go on to live meaningful lives after experiencing a code. These people are usually younger people who gave minimal health problems and a fixable problem that lead to the codes.

I've seen someone in their 50's code with VT due to hypokalemia after receiving hefty diuresis. He responded to defibrillation, coded again, responded to defibrillation again, and responded to potassium replacement when labs returned. One of the first codes I was in was another gentleman in his 50's or 60's kept overnight after a routine surgery. Coded. Very lengthy code but eventually achieved ROSC. He had a STEMI and recovered to discharge after angioplasty. Another code was asystole with sever hypoglycemia. Better after D50. A prime example I haven't personally seen is pediatric drowning codes. These are your 20 percenters.

Sour Lemon · Sep 8, 2017

I'm a nursing student and recently experienced my first code. I felt like I was the only person in the room that had any hope that this lady would make it (granted she was 80 years old) and thankfully she did. We Life Flighted her and she died at the facility that we sent her to. So I looked up the statistics of surviving a code and they are less than 20% depending on what website I looked at. Now I feel like what is the point of running when they call a code. Any suggestions? I am trying to figure out what my mind set should be then next time I go to a code.

We probably shouldn't be doing so many of them, but people often have unrealistic ideas about life and death. The ones who don't survive are sometimes the "lucky" ones.

AceOfHearts<3 · Sep 8, 2017

I recently had a patient that coded while not at any type of medical facility and a public AED saved their life.

Here.I.Stand, BSN, RN · Sep 8, 2017

Well we generally don't know going in who those people are who will do well. Should we give up on them? One of my more recent codes was for a mom in her 30s, hours after delivering a premature baby. Her children still have a mother. A man in his 40s was coded a LONG time -- over an hour on the LUCAS device!! Not only did he survive, but he returned to his high-pressure, high-thinking job.

Now we do definitely code people who should (in my opinion) be DNR/DNI. If someone has already sustained a brain stem stroke or anoxic brain injury, or other conditions with poor prognosis, elderly etc, we do know their outcome will almost certainly be poor. That really should be considered.

Why it's not...it's a complicated issue. Sometimes providers' communication is lacking. I remember being in a care conference for a woman who had a pontine stroke. When discussing options, the neurologist said "she would need 24 hr care, and she would always need someone to feed her." I cut in and said "just to clarify, by 'feed' you mean 'administer tube feeds,' correct?" I knew the answer -- that woman was never going to take anything PO! But I thought as a layperson, "feeding" her would mean spoon feeding.

Families made up of laypeople typically haven't seen a code, or poor outcomes following ROSC. They have seen on medical dramas though, where codes last 60 seconds and end well. Others have the misguided belief that agreeing to DNR is the same as murder.

When discussing with family, it's a fine line between being real, and being biased against coding.

Here.I.Stand, BSN, RN · Sep 8, 2017

And yes, as elkpark said, sometimes providers' decisions are influenced by the fear of litigation.

GSDlvrRN, MSN · Sep 8, 2017

For me, I want to honor patient's and families wishes. I worked at a nursing home for 9 months before my current job at a jail and I had some patients in their 90s (some on hospice), with low quality of life a laundry list of medical diagnoses and have had their share of surgeries/sentinel events (MIs, strokes, amputations, some were quadriplegic, etc....). I would think to myself "Why are they full code?!?!?!". I mean really, a code can be horrific! It was hard for me to think about coding someone who has already been through so much. Well, a lot of the time the family was still "hanging on," or there was a family member that was the designated "decision maker" or had medical power of attorney and had a POLST form stating the patient was a full code. It was very hard and ethically challenging to me to code some of these patients whose family decided that I am going to violently pump their chest and we're going to do "everything we can" if they code.

I hated it. I hated that a non-medical professional had legal authority to dictate what I had to do with MY patient who I just wanted to be comfortable and to die with dignity. I felt like, even though the patient had given someone else the right to make decisions for them, I really wasn't sure if it was what the patient wanted. I did it because it was my responsibility to honor the families wishes for the patient when the patient couldn't decide for themselves. I also did it because it was illegal if I didn't!

Editorial Team / Moderator · Sep 8, 2017

We do it for that small percentage of patients who come back and thank us later.

I bought my husband a coffee mug with a quote that says "To the world you may be one person, but to one person you may be the world." I look at every code from the perspective that while it's just another patient to us, that patient might be someone's whole world. To give someone the gift of more time with their loved one is a precious thing. Quality time, that is; I agree that sometimes we code someone because their family cannot yet let go, though they probably should.

That Guy, BSN, RN, EMT-B · Sep 8, 2017

Because the 20% of us who do survive are thankful for it. Im glad people didn't just look at me and go "why bother"

Cowboyardee · Sep 8, 2017

Because the 20% of us who do survive are thankful for it. Im glad people didn't just look at me and go "why bother"

"Why bother?" doesn't cover the real objections to overuse of CPR.

Lets start off with that 20% figure. Generally, that refers to the arrest to discharge survival rate for in-hospital cardiac arrests (the out of hospital rate is something more like 10%*). What you don't often hear is that approximately 25% of these individuals suffer substantial neurological debility after the cardiac arrest*. Ask any ICU nurse (I'm one, for whatever that's worth) about the number of people they see getting tracheostomies, PEG tubes, and being shipped to LTACs without any recognizable parts of their own personality left. So, you might reasonably lower that 20% figure having 'good' outcomes to 15%, right off the bat.

What's more, the immediate survival rate for in-hospital cardiac arrests is something more like 40%*. This means not only that 60% of CPR attempts fail, but more tellingly that a full 20% (those that survive the code but not the entire hospitalization) lead to what could very reasonably be considered a prolongation of suffering. It gives loved ones false hope and then snatches it away; it subjects patients to continued pain, distress, and discomfort.

The argument from many who take care of these patients is not that CPR is pointless; it's that our actions are making outcomes and quality of life and the dying process worse.

Of course, I'm not arguing that we should never attempt CPR or that healthcare providers should take it upon themselves to make decisions that are really up to the patients and their loved ones. But fostering a realistic sense of what CPR entails and its likely outcomes would be a great step in limiting the suffering we often cause. Healthcare workers in all phases of care need to understand this, and need to talk to patients and families early and honestly about what it actually means in terms of likely outcomes when our patients and their families ask that their 90 year old mother be kept alive by any means necessary.

I'm not trying to pick on you, by the way, ThatGuy - your post just makes a particularly useful quote. Hope I caused no offense.

1 - AHA Releases Latest Statistics on Out-of-Hospital Cardiac Arrest | Sudden Cardiac Arrest Foundation

2 - In-Hospital Cardiac Arrest and Post-Arrest Care - Strategies to Improve Cardiac Arrest Survival - NCBI Bookshelf

3 - Predicting survival, in-hospital cardiac arrests: resuscitation survival variables and training effectiveness. - PubMed - NCBI