"When you get those rare moments of clarity, those flashes when the universe makes sense, you try desperately to hold on to them. They are the life boats for the darker times, when the vastness of it all, the incomprehensible nature of life is completely illusive. So the question becomes, or should have been all a long... What would you do if you knew you only had one day, or one week, or one month to live. What life boat would you grab on to? What secret would you tell? What band would you see? What person would you declare your love to? What wish would you fulfill? What exotic locale would you fly to for coffee? What book would you write?"

Wednesday, February 24, 2016

To Code or Not to Code

Hello readers!

So I have a ton of homework to do, which makes me that much better of a blog writer! Hah. No really though, I write better when I'm avoiding doing something else. And I have a good excuse anyway, because this topic has been on my mind for about a month, clawing to get out.

Actually this may even count towards homework because I'm doing research on this for school, so boo yah!

Let me give you the first scenario I have, to slowly dip ya'll into my mindset here.

One month ago, I was assisting/as needed/general help down in our ICU department. After being there for a few, I quickly learned about a case down there. He was an 84 year old gentleman, who had been a code blue (he stopped breathing and no pulse) while on a Med/Surg Floor. He was a "Full Code" at the time, which means we do everything in our possible power to bring a patient back to the living world. We had brought him back to life, and any patient that goes through this automatically gets transferred to the ICU afterwards, no questions asked. There is never a case where we thump on someones chest and shock them and bring them back to life, and then are like, hey- want some apple juice? You seem fine to me! No.

So on he transferred to the ICU, hence where I met up with his case. I heard the ICU nurses talking, their "nursing spidey sense" that I know all too well was all in effect, as they all had a feeling this man was going to die that night again. However, this time his family had decided that this time he would not be a "Full Code". What happens if you aren't a Full Code? You have other options. But in my opinion (and I'll explain this more later) the best option is to pass away peacefully with lots of morphine and silence, and someone holding my hand so I know I'm not alone.

When the ICU nurses noticed his heart rate start to slow down, we knew impending death was soon. Our patient was trying to cross that line and was getting closer. We all agreed to go be with him, as his family had left for the night thinking he would make it overnight and they would say goodbye in the morning. Obviously that wasn't the case. We all stood by him, holding his hand, as we watched at his bedside his alarms going off, his heart rate slowing down dramatically, his breathing erratic. Me, being non-immune to all the alarms in the ICU, only heard the sound of the ventilator (breathing machine) pumping artificial breaths into this man, trying to keep him alive despite higher powers at play.

As sad as this case may seem (if you think that was sad, get your tissues out now), it actually wasn't as bad as it could have been. The reason this man's family didn't want him to be a "full code" in case he passed away again was because they had already seen him code the first time. The general public (hence his family) don't actually know what we mean when we say "Full Code". Doctors ask when you get admitted, usually regardless of your condition, "In the event of your pulse stops or your lungs stop breathing, do you want us to do everything in our power to bring you back?" Given that sentence, that sounds lovely, why yes! Bring me back! At the snap of your finger, or with your magical powerful wand. Bring my loved one back!  However, what most doctors fail to mention is what a Full code really entails. It's not quick. It's not quiet. It's not painless. And its certainly not magical.

For my non-medical readers, let me give you a quick low-down on what happens during a full code on a typical case. Please don't read this paragraph if you get queasy! But I do intend to paint an accurate picture. We automatically begin CPR. You all have seen CPR on TV at some point I'm sure, and the patient always wakes back up within a minute or two.  But have you ever seen CPR in real life? If so, you know that the recommended depth of compressions is 2-2.4" into your chest. Imagine someone right now pushing your ribs in 2", without you backing up. Pushing in 2" while you are laying down, helpless. Yes, ribs are usually broken. We also are doing this at 100 pumps per minute, no less. And we don't stop until the patient does return to life or a family member calls this effort off, or the doctor deems it medically impossible if the code has gone on too long. And that's not all. When we start doing compressions, someone is operating an external airway with whats called an "Ambu" bag, to deliver you 100% oxygen. This is only until we can complete something called "Intubation" where we insert a tube through your mouth and down your throat and into your lungs so that we can hook you up to a ventilator to do the breathing for you. Oh and that's not all.  If you have had anything to eat or drink within the last couple hours, what do you think is going to happen when we are jumping up and down on your chest? Yeah, it's going to come back up! When you're lying on your back unconscious! And we will suction as much out as possible, but it still will be everywhere.

So, that all being said, do you think if Doctors really painted that picture when we asked patients if they want to be a full code, do you think as many patients or patients family members would still want to be a full code? I don't think so. Now I've witnessed hundreds of doctors have this very conversation, and some paint a pretty picture and some don't. However, very very few actually go into detail about what really happens. Why not? Because it seems harsh! It is harsh! That paragraph above is horrible if you imagine it happening to you or your family member. If you get admitted with a broken arm, we still ask you if you want to be a full code. We ask everybody, because you never know what could happen. Life works in mysterious ways. Just a few months ago I remember a case of a man admitted with a UTI (urinary tract infection) but otherwise completely OK. Then BAM, had a massive heart attack while on our floor and coded. You never know.

So if you get admitted with a broken arm or a UTI, and here comes the doctor asking if you want us to save your life if you die? You're automatically going to be like WTF, I have a broken bone- are you not telling me something? Am I dying? If I'm not, why are you asking me this?

Or if the patient does understand the fact that this question is asked of everyone regardless of diagnosis or age, then many patients think that we are "giving up" or "won't treat" the patients condition if they agree to not be a full code. Their logic may be, "well if they aren't going to save my life then whats the point of even being here, or being treated?" Well that simply is completely logical. It is a reasonable way of thinking, but I assure you it is not true. I can say with complete and utter 100% confidence that I have witnessed on so many cases, where the doctors and nurses do so much to help a patient feel better or improve their condition, even if the case is eventually terminal. I promise you, healthcare will never ignore you or not treat you for your current condition as much as possible just because you agree not to be a Full Code if death occurs.

Now don't get me wrong at all, some people should be a Full Code! Absolutely! Let's say you do come in with that broken arm, or are having a heart attack, or a UTI, or whatever- but you are otherwise healthy- You live a happy, meaningful life- You should be a Full Code! You also have the best chance to also survive a full code as your body is healthy besides what is going on now. If we catch your heart stop beating immediately, chances are we will definitely get it back to beating within a very short time frame, especially if your body is remotely healthy. What irks me however is when doctors are unrealistic with those that aren't healthy. Those that come in with terminal cancer. Or have advanced Alzheimer's disease or dementia, or have any end-stage disease (heart disease, kidney disease, lung disease, etc.) Doctor's hit you with what I call a "Double-Positive Whammy", they make you think that death isn't impending soon from your disease, but just in case it is- If you are a full code, we will do everything in our power to bring you back and it will probably be successful! No.

I have been doing a lot of thinking on this and a lot of reflection within myself, my beliefs, my patients, my nursing practice.... and I still firmly believe in what I'm what about to say. I know a lot of people may disagree with me, and I encourage that- Everyone is entitled to their own opinions, especially with ethically situations such as these. I'm entitled to your opinion as are you.

I don't care if you are 18, or if you are 30, 40, 60 or 100.  If you have a disease that is slowly killing you, I see no reason to hold off the inevitable. Now that is a FINE LINE. For example, let's say a healthy person gets diagnosed with cancer. I completely support the notion of undergoing treatment  (surgery, chemo, radiation, etc.) I mean, you were healthy before! But what about after 10 years of treatment after treatment? How is your quality of life doing? Chances are, the patient themself already has a different opinion about their own end-of-life than their family or loved ones do. What I intend to make a point of here, is that regardless of age, if an individual either has a terminal disease, more than three major comorbidities (any major chronic disease that takes a significant toll on your quality of life), or are experiencing a poor quality of life (not eating, not happy, unable to do favorite activities, hobbies, cognitively impaired, etc) then in my honest opinion, they at least deserve the honest picture of what a full code truly means, and then they can decide. I'm not saying it should be mandated that these cases should automatically be a no-code based on an algorithm, that would be unethical. But they at least deserve the honest truth about the decision. The rest is up to them.

The last scenario I would like to share with you (if you are still reading) is a case that really pushed my feelings over the edge. Recently my unit took care of a very sweet elderly lady of the age of 96. She had multiple medical problems and was admitted with anemia (low blood count) due to gastrointestinal bleeding. She was with us for awhile with no events. Sent home. Family brought her right back due to intense abdominal pain. Again she stayed with us for awhile. Her blood counts kept dropping, there was no way to keep up with it. Her internal bleeding was too severe.  Meanwhile, she was absolutely miserable- She couldn't urinate on her own- leading to us straight-cathing her every couple of hours- she was in immeasurable amounts of abdominal pain, and she had a very poor appetite. And yet her daughter was her POA (Power of Attorney) and watched over everything regarding her moms care. And yep, You guessed it! This patient was made a Full Code. Decided by whom? You guessed it! The daughter.

One night, her vital signs started significantly dropping. The bleeding too severe for her body to compensate with. It came time that using our own nursing judgement, being that she was a Full Code, with the vital signs the way they were- she was quickly knocking down deaths door. If she was going to remain a Full code, we needed to treat her like a Full Code and get her to the ICU before she codes, that way she gets more intensive treatment to prevent that from happening. So we called what is known is as an RRT (Rapid Response Team) which is sort of like a pre-code. The patient isn't coding yet, but could be on their way soon if we don't fix the problem now. So of course during a RRT, a lot of healthcare personnel show up. Multiple RNs, Med Surg and ICU, 1-2 Respiratory therapists, a doctor or PA/NP, nursing supervisor, etc. We always draw bloodwork, usually put in a new IV. There's people everywhere and the bright lights are on in your face. Its like a code except you are awake and aware for it all. Well, this sweet lady is terrified and is screaming in pain. She's also crying, "Please, no." "Don't do this to me." "Let me die." "I want to die." "Don't do this." "stop this". And yet, because her daughter has the POA (who happened to be in the room watching this whole scenario unfold), the daughter has the decision on the code status. And despite her mom crying in pain and agony, the daughter demanded we do everything possible to save her. Maybe, maybe not- but if the daughter really knew what a code really meant, would she come to her senses and not want that for her mom?

If a loved one of mine were in the situation, don't get me wrong- Its awful. It's incredibly sad & frightening. But If i knew that my loved ones medical condition had made their life quality so horrible and they didn't want to live anymore, or they were in immense amounts of pain, I would never prolong the inevitable. I would of course want to treat them and care for them, but if the higher powers decide its their turn to go, then all I want for them is to not be alone and to not be in pain as they make that journey. I think that's the best gift I can give them as their own loved one.

Thank you for reading. I know its a hard topic, and a never-ending one. A very ethical one, and I know a lot of people will disagree with me. Chances are, not a lot of nurses will disagree with me, however. Because we see this every day. We see cases like these two every day. We are immune to the sadness, the awfulness of it all. We are trained to do what we have to do. If someone wants to be a full code, then so be it, we will  do everything we can to save your life. Just be sure its really what you want for yourself or your family member.

With love and passion for humanity,

A writer in a nurses body <3 nbsp="" p="">



Rosemary Engler said...

I totally agree with you. Often times, the person insisting on the code is not really thinking about the patient, but themselves, and their own fear of dealing with the loss. I think this is one reason a living will is so significant. The patient can declare their thoughts before they need someone else to make the decision for them. As you are a caring, compassionate nurse I admire your concern for the sanctity of human life and the wisdom to uphold your patient and their family wishes.

Anonymous said...

I agree with you that in every situation, the patient deserves to be made aware of the reality of the situation. That's what the idea of informed consent is all about, and I believe it applies to code status.

I also agree that healthcare staff don't have the right to decide the validity of someone's code status. We have no right except to honor their wishes, even if it's not what we would choose. It doesn't bother me if it's truly what the patient wants.

Unfortunately, in some cases, code status DOES lead to substandard care. At an LTACH I had doctors reply "The patient is a DNR" on more than one occasion when nurses were advocating for some kind of intervention (Their HR is in the 40s and you don't want to do anything?! YOU DO UNDERSTAND THEY'RE NOT DEAD YET???!?). But that's a place I severed ties with for many reasons, and that attitude has not been the norm in my other experiences.