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.


  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.

    Donovan (from UCSC)

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

  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!

  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.

    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.

  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!!

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