Friday, April 3, 2009

PSA: What "Full Code" really means for your loved one

I received a transfer patient from another unit. 87 year old female, baseline A&0x1 (A&O = Alert and Oriented, to Person, Place, and Time) and barely verbal. Diabetic with history of ulcers and multiple toe amputations. Wheelchair bound at home. End Stage Renal Disease with dialysis 3 days a week. Almost blind. Here for sepsis and pneumonia. Quality of life? Not so much.

So she comes to me and I start doing my assessment. She requires a "shake&shout" just to get her to open her eyes. When I go to check her name band, it is stuck to her skin, which is thin as tissue and nearly tears when I try to separate the band from her wrist. She moans with pain but doesn't open her eyes.

The doctors are at the desk going over her chart to figure out if she needs any new orders on this unit. I mention that she does not look good at all, and that I was told in Report that she was "full code" but it didn't seem right to me at all. One of the doctors said he'd seen her before, last year, and that she was DNR/DNI (Do Not Resuscitate/Do Not Intubate) and that he was pretty sure she still was. We go through the chart to look for the "code status" paper. There it is. "Full Code".

The doctor sighs and I say, "I don't think people really understand what full code means in real life context. They see a code on TV. There's some CPR, there are paddles, maybe some drugs given. And 30 seconds later the patient is back, right as rain. If they knew what it really meant, I think a lot fewer people would choose this for their loved one. Are the risks of resuscitation really explained to people when they determine status?"

The doctor agrees. If someone tried CPR on this frail little old lady, her ribs would shatter. He decides we should call the family member to confirm code status. The doctor finds a half-assed "Advanced Directive" paper in the chart that says the patient doesn't want to be kept alive on machines. But doesn't specify if she wants to get put on the machines in the first place. He tries to take this angle when he talks to the family member. The family member insists that she would've wanted to be full code. The doctor acquiesces and makes a note of it in the chart. I look at the clock to see how much of my shift is left. Less than an hour. I hope she doesn't code on me.

If you are over 70 years old your chances of coming back after resuscitation are less than 15%. This doesn't mean "back to normal". This just means "no longer being technically dead". Your chances of surviving increase to about 50% if your death is witnessed by medical personnel, but only about 20% of *all* resuscitation survivors (from young to old) live long enough to be discharged from the hospital. Compare that to the survival rates from TV: CPR brings'em back 75% of the time, and they're usually fine afterwards.

As you age, your bones become more brittle. Your cartilage loses its springiness. During chest compressions, we have to use about 100-125lbs of force to get to your heart. Over and over and over. 100 times a minute.


Think about your grandmother for a minute. How well do you think she'd do if she was hit in the chest with 100lbs of force more than once a second? Imagine being 85 years old, having died temporarily, waking up with fractured ribs that cause a stabbing pain with each breath. Now know that there's an 80% chance that she will spend the rest of her short life in the hospital, in pain.

Then there's intubation. If for some reason grandma's airway isn't open enough, they'll stick a tube down her throat into her lungs so they can ventilate her that way. Have you seen what they use to get the tube in there? That thing is made of metal, and if the person's mouth is small, or jaw doesn't open enough, or the doctor *can't quite* see the vocal cords, there's a good chance grandma's gonna end up with chipped/broken teeth. If grandma survives long enough to be extubated, there are other problems. The tube has to go between the vocal cords. It'll be very hard for her to talk. Very bad sore throat. And if it stays in long enough, the muscles may be impacted. This means difficulty swallowing.

Difficulty swallowing could mean a couple things. If it's really bad, like everything she tries to swallow goes into her lungs, we won't let her eat. Because food in the lungs = pneumonia = death. Not good. So we'll keep testing her swallowing every day, to see if it gets better. If it doesn't we'll put a tube down her nose to give her liquid nutrition. She will hate the tube. If the trouble swallowing isn't too bad, we'll put her on "aspiration precautions" and she will need to be fed by someone. If family is there, good. They can help out. If not, it falls on us.

These days on our unit, we're short staffed. We have one CNA on the floor trying to do everything for everyone. We have one UA (unit assistant) trying to get our orders entered into the system in a timely manner. This means that a lot of the little things fall on the RN's shoulders. I'm not saying that we shouldn't have to do this stuff. These people are here to help. If they can't, then it's our job. And that's ok. But there's only one of me and if I'm trying to pass medications and start a blood transfusion and make sure my confused patient doesn't get out of bed and fall and trying to get one patient off to CT while taking report for an admission... you can see how something like feeding a patient might get pushed off for a little while. I always try to make sure my patients get fed during my shift. But it's not uncommon to see unopened trays of food sitting on tables in front of people who can't feed themselves.

So now grandma has pain with every breath, a crazy sore throat, maybe some chipped teeth, and hasn't eaten for 2 shifts because she's either NPO or her nurse didn't have time to feed her.

Oh. And then there's hypoxia. It only takes a few minutes for brain cells to die from lack of oxygen. A patient would be very lucky to have medical personnel in the room at the moment of coding. It dramatically increases immediate survival rates. But a nurse isn't going to spend the entirety of a shift in a patient's room just in case. It's just not possible. So the more likely scenario is the nurse comes by the room while rounding, or during medication time. Sees grandma lying there unresponsive. Checks her "brain" (paper used to write down report info) to confirm the code status and goes "oh shit oh shit oh shit what do i do?"

We don't know how long grandma's been unconscious/dead. Two minutes? 10? There's no way of knowing. But we call a Code and start CPR and do everything we can to bring her back. If it's been too long without oxygen, maybe we won't succeed. But maybe we will. Miracle of miracles, we get a pulse back, she starts breathing again. However, the lights are on but nobody's home. She's gone without oxygen for too long and she's in a coma. Or a vegetative state.

The grandma you knew is gone. She can't talk, can't move, can't open her eyes. Now she's definitely getting a tube for nutrition. And she needs to be turned every 2 hours to prevent pressure ulcers from forming. And that's going to hurt because her ribs are broken from CPR. And she has an 80% chance of dying permanently anyway during this hospital stay.

All because you decided that grandma should be full code. If grandma has had a good full life then please, let her slip quietly into the night. Think about her current health. Think about the pain this could cause her. Think about the quality of life she'll have if she does manage to survive. Being Full Code doesn't guarantee a good outcome. If you love your loved ones, let them go when it's their time.

Making your relative DNR doesn't mean we stop giving care. We still treat their diseases, provide for hygiene, prevent pressure ulcers, and try to make them better. But if it's their time to go, we let them go peacefully.


The next day when I came for work, I asked how the patient had done overnight and through the day shift. I was told that the doctor talked to the whole family, and they agreed that the best course was to put her on End Of Life Care (EOLC). This means we no longer try to treat her diseases. We make her as comfortable as possible and allow her to die on her own time. Thank god the family finally saw reason. I like to think the doctor told them what Full Code really means and that a little education went a long way.

18 comments:

  1. K -

    Thanks for sharing this. I've watched a little too much TV and have a rosy view of Full Code as a result.

    That said, my grandmother's husband died recently but my Uncle walked in just in time to perform CPR. He's now back home, walking around, and while in pain, definitely happy to be alive.

    The man is built like an ox.

    How cool that you're nursing now. Thank you for doing it, I'm glad to know someone like yourself is out there helping folks.
    Best,

    Donovan (from UCSC)

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  2. nice post...could see how it was helpful to your friends' relatives.

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  3. WONDERFULLY written! I worked as a respiratory therapist for 13+years and have felt the same so many times. I've had those ribs crack under my palms as I'm doing my compressions...It's a pity more people don't read this! I have known some fantastic doctors who could get no code status on these very people because of the very realistic way they presented what would be done if grandma WAS a full code. I think more teaching needs to go towards interns presenting the real picture not the TV version. Thank you!

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  4. Yes! If DNR's are used responsibly with the CONSENT of the competent elderly patient or a surrogate family member, death can be more compassionate for the elderly patient who elects to die sooner rather than later because they have elected to forgo a hospital procedure that would extend their life.

    But if DNR's are used indiscriminately to frustrate full codes as a means of reducing the costs of caring for elderly patients, this can lead to abuse of DNR's whose primary purpose may be to cut the costs of treating the elderly person by cutting their lives short.

    Full Codes offer protection to hospital patients of all ages and should only be overcome by the informed consent of the patient or the patient's surrogate ---no matter the age of the patient.

    Hospitals should continue to make sure that there is informed consent to any DNR that is put into the hospital chart to defeat "full code" as a means of protecting the elderly from "market forces" who want to reduce the cost of treating the elderly in the late stages of their lives in order to preserve profits.

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    1. The issue here is that consent is being issued with out the informed piece. People think we will be able to bring back their loved one when in reality if we do it will be a shell of a person. I've never seen a DNR place on any patient irresponsibly, or for monetary gain, I have however seen MANY MANY MANY instances of full code status that would result in further pain or simply not work. I have collapsed a mans chest doing compressions before while we watch the clock for when we can let this man go in peace. I can assure you no nurse is thinking about insurance or the cost of resuscitation when that code alarm goes off and bad physicians don't want their patients to be DNR because they make no money off of a dead patient. Good physicians are the ones who sit down with the patient/family members and explain to them what we ACTUALLY do when we run a code, how it works and how it all works together (so that if a family says to make them a chemical code the doc can explain that epi isn't going to do anything without compressions) and what the patients real chances of surviving are and what quality of life they are likely to have if they do survive. I've taken care of children who have been brought back who are vegetables and it has honestly made me question if I would even allow resuscitation to the young.

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    2. Anonymous you are right. I have NEVER seen a DNR order done for any reason other than humanitarian. Shame on ANYone who is so misguided as to believe that the staff caring for that human being has some monetary vested interest. That just speaks more to paranoia and too much late night TV,

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  5. My 88 yr. Old uncle has been in and out of the hospital and nursing home five times in six months. My cousin, his proxy, insists on full code because he says his care will be better and he's most likely to die in the hospital. The hospital has been pushing for the proxy and my uncle to sign a DNR and to discharge him. He has aspiration pneumonia, had mini strokes, in and out of consciousness, sepsis, mrsa, c diff, on peg tube for four months, aspiration pneumonia for more than four months, severe arthritis exacerbated by the sepsis, etc. Etc.etc. Hospital wants me to try to talk to my cousin, the proxy and convince him to send my uncle to a hospice hospital. I'm torn...any advice would be welcomed!!

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    1. Are you keeping him alive you, or for his sake. Your uncle is suffering and all the extra things done for him is only prolonging the inevitable. Ask yourself, "would I want to live like that? I'm a nurse who has seen plenty of suffering, and would not put a family member through all of that. Hospice is wonderful! They care and give quality end of life care. Comfort measures are the best!

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  6. The humane thing would be to let him die with dignity....it's his time, the suffering needs to stop.

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  7. I worked in critical care for awhile, and have been a nurse for over 27 years. I've never seen a hospital use DNR to save money, but I have seen numerous families use Full Code to cash another social security check or to further their own needs. Meanwhile, the nursing staff are the ones spending the final moments with patients. Full codes are barbaric in cases of patients who are essentially dying anyway. During my time in the ICU when there was a full code on a patient I always brought the family member into the room, so they could be part of the decision making process, never once did they say to continue.

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  8. This should be in the hands of every Estate attorney. Must reading for the heirs.

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  9. Quality v.quantity. life is meant to be lived. When you can no longer have quality and happiness and find joy in your surroundings and there is suffering....give the best most important gift ever...a death with dignity and peace.

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  10. My mother had a DNR in the nursing home, but nobody reminded us of that when she went to the hospital with an infection. They had to cut back on her heart medicine, and two days later, her heart went out of rhythm. When the nurse saw that she was dying, she immediately called for another nurse, who responded tht she had a DNR. So they let her die. This may have been the best thing, because she probably had a stroke while in the hospital, but it was a shock for me, and I would have liked to have been prepared. So please, when you admit someone to the hospital, go over the orders with the family, so they know what to expect.

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  11. In my years as an ER and ICU Nurse I've had this conversation with many, many, many family members. It is a horrible, gut wrenching thing to discuss. It is however my duty to be an advocate for my patient while still providing support and teaching for their family members. Too many times I can remember the knee jerk reaction being to "do everything you can" because it is beyond thought to be without this vital, wonderful member of your family. The best thing that can be done is to very bluntly but clearly verbalize what "coding" the patient means. I will put my fists in the middle of their chest and press down with as much force as I can generate, which will squish their sternum down on their heart, breaking numerous ribs in the process. When I feel their ribs break under my palms I know I'm doing it correctly, this will pump a certain amount of blood through their system. We will stick a tube down their throat to take over the process of breathing for them, this does not mean they will ever be able to do it on their own again. We will give them drugs which will possibly help bring back cardiac function, this does not mean that it is sustainable or will last for very long. More often than not when the drugs begin to wane, the entire process will be repeated, numerous times until we can no longer bring them back from the edge, or until their family asks us to stop the battle. It is an extremely beautiful thing when all comes together to restore a patient to their full bountiful life, this is truly God at work through our hands. More commonly the patient passes despite all of our best efforts, numerous battles with the angel of death and truly despite anything we attempt to do. This is also God working through our hands, He has a plan and nothing we do can deter Him from the result that was meant to be. When that time comes we move from the role of warrior to the role of comforting loved ones and holding their hands through their sorrow. It is excruciating to look families in the eye and explain the process, but I would rather prepare them for what is to come than have them day "why didn't you tell me?"

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  12. I completly agree with your assessment and as an ICU nurse I unfortunately see this every day. The really frustrating part is when you know the family member is benefitting in some way and keep their relative alive for selfish reasons. Sometimes though, it takes the family being at bedside during the code for them to realize the horrible things being done to their loved one. Maybe there should be a realistic video for families who are required to make this decision, to reinforce physician education.

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  13. Unfortunately, some healthcare providers do use dnr as a directive to withhold care making family reluctant to go with that designation.

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  14. If you don't currently have a living trust with a living will documenting your wishes you are an idiot. I don't care that you are 25 years old, young people die too. Get the documents done and let someone know where they are and what's in them. Assign the family hard ass to be the decision maker so family pressure doesn't invalidate your wishes. No family hard ass name a trusted friend or name the attorney that helped you write the documents. Also consider what to allow should you be injured or ill and suffer brain injury and live. My living will specifically states that no one is allowed to feed me by tube or by hand. My post brain injury stay in your unit will be blissfully short.

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