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="">




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Life in the Middle Lane

Hello lovely, lovely readers! You are lovely because you still read this blog, even though I never post as much as I should! I really do always have a lot to say, just never the time, or balls, to actually say it.

I write this blog today because I've just about exactly hit my "Two Years" Nurse Anniversary. This is a definite bittersweet anniversary/year.

Lets discuss.

It is sweet because, hell, I've been a nurse for two years! I've SURVIVED! If I can survive this long, chances are I'll survive the entire career. I've made it past that point where I doubt myself every minute of every shift. I've made it past the point where my coworkers doubt me every minute of every shift. (Now only some coworkers do, lol). No really though, in all seriousness, I've been on two very autonomous, heart-wrenching (literal and figurative), fast-paced hospital nursing units now, and I can proudly say I've seen and done a lot in those two years where I legit feel comfortable with my knowledge base now. So much so in fact that I'm craving more knowledge. 


This is also the problem, knowledge. Now, roll with me guys. Does it make sense at all, if I tell you that despite what I just said above, hitting the two-year mark also means I'm hitting the "I've been a nurse for two years and I still don't know what the hell I'm doing" mark? I know you're confused but let me (try) to explain. Despite having a wide array of skills and a comfortable knowledge base that has grown in these two years, there is still so much I don't know. And I understand that nurses feel like that after fifty years of nursing, too. There's always going to be something new or confusing. I know enough now where my unit seems to think I'm charge-nurse quality and I'm frequently elected charge nurse to this telemetry unit, where I'm in charge of 2-6 nurses and 14-36 patients at a time. And yet when I am in charge, there are still so many times I run into a new situation that I don't have an answer to. And those times, I have nurses that need those answers from me, like I needed from my superiors back when I first started. And that's batshit crazy.

It's just, nurses are required to know the entire body system. Even though I work on a telemetry cardiac-focused care floor, the heart can affect many other organs and I must be prepared to handle anything. And there's so much to know and remember I don't think I'll have it all down by the time I'm retired, but I'll always be trying. I want to be the nurse that knows everything, that can help everyone, my staff and my patients. I want to always have an answer. But as the saying goes, the nurse that knows everything can be the most dangerous. So I have to be patient with myself. I have to accept the fact that it's okay to not know everything. But I'm finally at the point where at least I know a lot of things.

So that's where I am now. But looking towards the future, I'm still at a loss. I don't want to become stagnant In my position, I want to keep growing. I talk to my patients in their 80's that tell me they worked the same job for 50 years and I can't even fathom that. I know that generation workforce is entirely different than the one today. Not only could I not last 50 years in this position, but I feel almost pressured to move on. Like good nurses are supposed to keep growing, keep changing, keep moving to different units so their knowledge base becomes even more diverse and themselves more experienced. Like If I stayed on this unit for 10 years and did nothing else, I would feel like nothing. Like I'm taking my life nowhere, In no direction.

So now that I've hit that two year mark where I feel slightly confident in my skills, I feel that pressure that I need to do something else with those skills. I've recently successfully passed ACLS, which stands for Advanced Cardiovascular Life Support, which is a major step up from only being allowed to do compressions and airway support with just a BLS (Basic Life Support) Certification. Now with ACLS I can direct and lead a code blue in an emergency situation, even without a doctor being present. I can push life-saving medications into a patient during, just before or just after a code. I can participate in advanced airway management techniques now. So this has quenched my thirst for more self-evolution and knowledge, but only temporarily so.

So where does that put me now? Well, I want to go back to school. Not only because I just actually really do like school, but because that's the ticket to advancing my career. The only major problem is, what career?  Applying for a masters in nursing is like a senior in high school that is trying to pick a career out of all the choices in the world again. Yes I am trying to advance my career in nursing, but in what route? There are so many choices and routes that I could potentially see myself being successful in, but how do I know which one I actually will be happy in? I can't get a degree in everything (as much as I'd like to), so I have to be sure.

I've debated starting to a local program near me that is for a "Nurse Executive" degree, basically a dual-degree of MSN/MBA. It would take forever and be super expensive but would put me down the road of maybe eventually being very high up in the hospital administration pool one day. But as high-paying, important and as cool as that is, is that really what I want? To leave the patient bedside? To lose what it really is to be a nurse? To hold someone's hand and tell them they are not alone and will be okay? To instead be in an office making and revising policies, firing and hiring people and enforcing rules? Is that what I want? I don't know yet.

I've also been interested in the future of nursing informatics, but I would also completely lose the bedside nursing aspect there, too. With a degree in there I could help formulate programs and design new computer charting for nurses. I've also fantasized about working in epidemiology, where I could easily travel and investigate new diseases around the world and help stop or control them.  I'm also very interested in the route of emergency nursing, where that would keep me at the patient bedside, but in a totally different manner. I'm slightly interested in ER nursing, but even more interested in field nursing, but even that has many different routes. I could do pre-hospital nursing (riding with ambulances providing pre-hospital care), or I could go completely crazy and apply to be in a disaster relief system to travel to new disaster areas and help triage (that really is crazy I don't think I'd actually do that). I'd miss my kittens too much. ;-)

But can you see how overwhelming this could be? That is the blessing and the curse of nursing. Just because you're in nursing as your one career, does not make you limited. I can still pretty much do anything I want and that scares the shit out of me.

So that's where I am. I know a lot but am craving to know more. I've been a nurse for two years and don't know where I'll spend the next 30 years. So (too) many options.


I just try and like....meditate, and try and picture myself in the future, what am I doing and am I happy? And I just can't see it. I guess that's because I can't tell the future....makes sense I guess.



Anyway, with love.....


~WNB





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