Why do we do codes?

JKL33 · Sep 8, 2017

Thanks Cowboyardee. I understand the emotional nature of this topic, but I still hate to see it devolve into implications that are pretty much the same as saying the question is invalid and the asker lacks morals/ethics.

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I'm a nursing student and recently experienced my first code [.........] I am trying to figure out what my mind set should be then next time I go to a code.

Dear scrubs,

First, please know that your questions and conflicting feelings are pretty common in nursing (from students to even experienced nurses sometimes feeling great conflict over "what we've just done"), and watching a first code can be especially poignant.

One thing about having these experiences is that you can't (or don't usually) come out of them without opening the door that leads to learning something about yourself, others, and the world/humanity in general.

The obvious reason we perform resuscitation measures, generally speaking, is because some people can be resuscitated and return to an acceptable quality of life. But for various legal and emotional reasons, situations of conflicted ethics often arise (or perhaps I should say situations where ethical principles might appear to be conflicting).

What I've personally observed over the years (as merely one of many factors that weigh heavily on this issue) is that "DNR" originally was a decision/declaration that patients could make because they didn't want certain resuscitation measures. That was wonderful - - they know that we might do something that they wouldn't want and they are able to say "If I die, please don't do that to me" ahead of time. Things have kind of become twisted where, in addition to that, people (well, usually their families) say, "you have to do X, Y, Z" or "she wants everything done" - even though we were never doing "everything" to begin with, but rather "everything that was considered to be helpful and not futile."

This issue is way more complicated than just "well duh, we do them because who are we to judge someone's quality of life?" This is a topic that can't be discussed from solely an academic standpoint nor from solely an emotional standpoint.

I think that while you're a nursing student you should allow yourself to simply take in these experiences and mull them over without feeling as if you must come to hard conclusions about every situation like this where there are different angles to consider.

Elvish, BSN, DNP, RN, NP · Sep 8, 2017

Some people do make it. I have coded newborns at birth that went home with their moms two days later perfectly fine.

If it's a witnessed code the person has much better chances, as do children (generally speaking, not always).

Like a PP said, this is when it gets real important to have those difficult uncomfortable conversations about end of life wishes. About exactly what a code entails and about exactly what the person's quality of life may/may not be when they're resuscitated.

I was furious when I found out my late uncle was a full code despite having stage 4 colon CA with extensive mets. No one had clearly sat down and talked to him about what a full code entails. I would have flipped my lid if I'd walked into his room and found anyone resuscitating him, causing him more pain on top of what he was already dealing with. Once we had the Big Talk, he agreed strongly that he wanted to be a DNR and he went into hospice a couple weeks later.

There's so much that depends on the who and the what when thinking about why we code someone. I'm 38 and in decent shape. If you see me fall out on the ground, please crack a few ribs and try to bring me back. I've got 2 kids I want to see grow up. (That said, I've seen women younger than me have amniotic fluid emboli that led to a code lasting several hours and they still died. But we coded them anyway bc we wanted to say we'd given them a fighting chance.)

Editorial Team / Moderator · 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"

Glad you are OK! I had my own cardiac scare last month â€” peripartum cardiomyopathy â€” and I would hate to have an issue and end up on the wrong side of "why bother."

JKL33 · Sep 8, 2017

Glad you are OK! I had my own cardiac scare last month â€” peripartum cardiomyopathy â€” and I would hate to have an issue and end up on the wrong side of "why bother."

Holy cow. Glad you are okay too!

I haven't noticed that situation being one where people are likely to feel that aggressive treatments and resuscitative measures are a "why bother" situation, though. :)

Sincerely, without discounting anyone's personal experiences (and I've been through a terrifying situation with my own child) - may I ask why this discussion must become about "why bother" rather than the fact that this is an issue that emcompasses all four of the basic medical-ethical principles?

Horseshoe, BSN, RN · 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"

THIS. This is the reason we do codes. There are plenty of times where it is not appropriate, and we need to get better about making those distinctions and educating families when their loved ones fall in that category, but we don't just throw the baby out with the bath water.

Amethya · Sep 8, 2017

Can you imagine how it would be if we didn't?

"WE HAVE PATIENT SMITH DYING IN ROOM 10! HURRY!"

"UM... PATIENT JONES IS HAVING AN HEART ATTACK IN ROOM 8, FYI"

"SO... I NEED A DOCTOR IN ROOM 34, MY PATIENT DIED."

kbrn2002, ADN, RN · Sep 8, 2017

Yes, most don't survive a code. Or survive the code and die shortly after. Or survive the code and have disabilities afterwards that may be permanent. But, there are that few that survive. Usually younger, previously healthy individuals with a sudden cardiac arrest and hypothermia or young drowning victims. It's the elderly folk with multiple comorbidities that insist on a full code status that get to me. We recently coded a 99 year old, it was not successful.

Unfortunately I do think that the media plays a small role in people insisting on full code status that really shouldn't. TV dramas show a patient down for over an hour that miraculously comes back with no cognitive deficits from being oxygen deprived. Even news outlets tell the miracle stories of people revived. Surviving a code intact is rare enough that it makes the news and people wrongly assume that everyone can be brought back to life.

Susie2310 · Sep 8, 2017

I read the updated American Heart Association statistics for 2016 adult in-hospital cardiac arrest survival to discharge were 24.8%. Virtually a one in four chance of successful resuscitation. To many people, whatever their age, that is a chance well worth taking, and to many of their family members that is a chance well worth taking. At the time of arrest the patient is pulseless and unresponsive, and will die within minutes if resuscitation is not attempted. True, advanced age and multiple co-morbidities decrease the likelihood of a successful resuscitation, and the possibility of incurring new deficits/injuries as a result of resuscitation that would amount to a reduced quality of life exist even if the resuscitation succeeds. However, much depends on other factors: the quality of resuscitation given; how quickly the patient is found to be unresponsive and pulseless after arresting; the quality of the CPR the first people responding provide; how quickly the Code team reaches the patient; etc. So there are many variables. Also, many of the causes of arrest are correctable and reversible.

I think it could be helpful for patients and their families to be informed in a considerate manner that resuscitation carries risks to one's health too even if the resuscitation succeeds, with an explanation of these risks using a source such as the AHA, but I still firmly believe in the patient's right to make their own decision about whether or not to be resuscitated, or to appoint family members/significant others as their decision maker/s.

hawaiicarl, BSN, RN · Sep 8, 2017

What a great topic!

I was in shock my first code here in the US, the patient had a living will that said DNR. I asked the physician after why we coded a DNR patient, and he said because the daughter demanded it, and that the patient is going to die either way, but if we didn't she would sue. I was flabbergasted. Another time, we coded an 80+ year old dementia patient because her family was living in her house cashing her social security checks, stayed in hospital vegetative for over a year ...

I have been in critical care for almost 30 years, can't even begin to count the number of futile frustrating codes I have done. Like others have pointed out though .... once in awhile one makes it with no deficits, that is a rarity, but definitely a win.

As you continue your nursing journey you will struggle with futile care decisions until you retire.

What a ramble, maybe I should put in paragraphs so it's not a wall of text .... done.

Cheers

Mavrick, BSN, RN · Sep 8, 2017

Dear OP,

You are in the Transition Zone, (i.e. where a layperson becomes educated as a healthcare person). The entertainment industry has a huge love affair with high tech medical miracles. They make it seem like it happens everyday and pretty much to be expected that we can bring everybody back from the jaws of death to wake up and resume their previous life. Maybe even with improved function or superpowers.

Actually, we do CPR on dead people.

The reality we (ex) ICU nurses see is the futile efforts practiced on persons actively trying to die. I have seen codes used strictly as learning experiences for Residents to try intubating, central line insertion, chest compressions etc. Crackling ribs and frothy respirations do not make a pleasant soundtrack for TV medical dramas, so that part of a code is conveniently left out. The fantasy version of bringing the dead back to life is what everybody wants. The serious conversation about what really happens in and after a code is what nobody wants.

brillohead, ADN, RN · Sep 8, 2017

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This is what gets to me. I work on a cardiopulmonary floor filled with congestive heart failure patients and COPD patients (and often CHF patients with COPD as well). The majority of our patients are >80yo with questionable quality of life already....yet the majority are also Full Code.

Add in the dementia patients, and it just seems downright CRUEL to put these people through a code. But if anyone tries to have The Big Conversation with anyone, it devolves into talk of "death panels" and whatnot. :rolleyes:

There's a difference between "living" your life and "being alive". Wearing diapers and having someone shove a pillow under alternating butt cheeks every two hours while staring blankly at a wall is not "living" to me.

Life is not intended to be infinite. When you've reached the end, it's okay to let go.

Susie2310 · Sep 9, 2017

This is what gets to me. I work on a cardiopulmonary floor filled with congestive heart failure patients and COPD patients (and often CHF patients with COPD as well). The majority of our patients are >80yo with questionable quality of life already....yet the majority are also Full Code.
Add in the dementia patients, and it just seems downright CRUEL to put these people through a code. But if anyone tries to have The Big Conversation with anyone, it devolves into talk of "death panels" and whatnot.
There's a difference between "living" your life and "being alive". Wearing diapers and having someone shove a pillow under alternating butt cheeks every two hours while staring blankly at a wall is not "living" to me.
Life is not intended to be infinite. When you've reached the end, it's okay to let go.

The difficulty I have with this post is that the poster is speaking from his/her point of view, which is fine, except their post doesn't include or allow for the patient's point of view. >80 year old patients even with multiple co-morbidities and what appears to other people to be little quality of life may indeed feel they have a high quality of life and wish to continue living. They may have many reasons to wish to continue living. This is where I feel health care sometimes gets it wrong; when we try to project our own values/perceptions on to the patient. I read of a study where patients who were "Locked in" utilized a tool to communicate with and reported good quality of life and the desire to live. So we need to be careful. The question is: The patient's condition and co-morbidities notwithstanding, does the patient wish to be resuscitated or not? Very often the patient makes decisions regarding resuscitation with their family/significant others, or appoints a decision maker who they trust to carry out their wishes. These discussions and decisions very often take place privately, and as nurses we are often not privy to how or why the decisions are made, and we just learn that the patient is a Full Code or a DNR when the physician makes them a Full Code or DNR. Just because some decisions appear inappropriate from our perspective does not mean that the patient and their family have not put a lot of thought into them.

Of course, other situations occur, for instance where the patient's wishes are clearly not being followed/respected, but that is not the situation I am addressing in this post.