Sunday, July 06, 2008

Can we just print this out, post it on the fridge, and be done with it?

You know it's going to be a bad day when you walk in and somebody immediately calls a code.

Except this one wasn't a code. It was, technically, a "Rapid Response Team" situation, but given that the patient ended up intubated and 100% ventilated, it was a code. But I'm getting ahead of myself.

A lot of families hate the idea of signing a DNR (Do Not Resuscitate) on Grandpa or Grandmother. They think that a DNR means "Do Not Treat" or "Ignore" or "Hasten the Death Of" rather than what it actually means.

To wit: Grandpa was not in the best of shape when he came to us X days ago. He'd had two major ischesmic (clotting) strokes and a large, horrible bleed in his brain and was breathing irregularly and gaspingly when he was delivered to us by a relieved ambulance crew. Grandpa hadn't moved on his own or responded to anything short of pretty intense pain for days. Grandpa was a full-code, or a "Do anything and everything to save this person's life" when he came to us.

Let me be totally clear here: Grandpa was in no way, shape, or form, ever going to get better. The best neurologists and neurosurgeons in the country had already determined that. Okay? Okay. You got it. Grandpa's gonna die; the only question left is how.

So I wander in to work, already tired and strung out from the sort of weekend nobody wants to have. After I'd been there not three minutes, somebody hollers out of Grandpa's room to call the I did. Despite not being on the clock and not officially there yet, I called RRT. (My compassion continues to overwhelm me, as I'm sure it does you.) Then I wheeled myself and the code cart into the room and took a good look at what was going on.

What I saw was an 87-year-old man in the last stages of life. Agonal breathing, cold extremities, you name it--this guy had a bus to catch and was running after it as fast as he could. Family, being in the room, was flipping out and demanding we "do everything".

So we did. Those of you with relatives who are in the "do everything" camp might want to cut this bit out and show it to those relatives. Here's what we did:

We started three large-gauge IVs in the man's arms and legs. We called an anesthesiologist (who just happened to be wandering past) into the room to intubate, as Grandpa was not breathing well on his own and bagging him (ie, providing artificial respirations with a manual device) wasn't working. 

The anesthesiologist had to try four times to intubate Grandpa. His airway had been damaged by people suctioning it out in a ham-handed fashion. When I finally got a 16-French (read: small) bougie up, Anesthesiologist guy managed to get it down Grandpa's throat at the cost of a whole lot of blood being shed from those damaged throat and airway tissues. There was blood everywhere. 

At that point, Grandpa stopped breathing on his own, following the natural course of things, and we had to do chest compressions. You could hear the sound of his ribs breaking outside the room. I broke at least three of them myself, straddling this ancient man and counting "one-and two-and three-and...." and trying to get three inches depression with each push.

There were people bagging and cursing and blood flying everywhere as Grandpa's arms jerked with the compressions, ripping the needle that the respiratory guy was using to draw labs out of Grandpa's arm.

We pushed drugs you've never heard of more times than is interesting to tell about in an attempt to get a heartbeat, *any* heartbeat, on this man. You can't shock a flatline, and we didn't...but we didn't get much of anything out of him. IVs in his arms blew as we pushed drugs too fast, raising enormous discolored lumps on his arms. We replaced the IVs with ones in his legs and a central line in his groin, the only place we could find a vein that was engorged enough to poke.

Every time the doc who took over compressions from me pushed, more blood would squirt out of the various holes we'd made. This was not natural bleeding; this was artificial bleeding from a dead person that was caused by us forcing his heart to squeeze.

Finally, finally, with family in tears in the hallway, we managed to get a shockable heartbeat. And finally, finally, we put on external pacing pads that would deliver a mule-kick through the man's shattered chest every few seconds in an attempt to remind his heart to beat. And finally, finally, *finally*, with blood bubbling out of the breathing tube (from the broken ribs) and oozing out of the various holes I and my colleagues had made in him, we managed to get him stable enough to take him up to the ICU and put him on a ventilator to breathe for him and drugs and drips to keep his blood pressure stable.

That, my friends, is what a code is like. 

That is what you're wanting for your family member.

And this was a clean code. That's the horrible thing: we only coded this guy for a total of about five minutes; the rest was all pre-code intubating and sticking. 

If you come in with a DNR, I will bust my balls to save your life. If it comes to it, though, and you stop breathing on your own, I will not torture you in order to get a few extra minutes of fake "living" out of your cooling carcass.

If you come in as a full code, I'll bust my balls to save your life, even to the extent of breaking your freaking ribs in the process. I'll hate it, but I'll do it.

Talk to your families, people. Decide how you want to go. But please, please be aware of what you're asking when you ask for it.


Anonymous said...

We nurses have a unique view on this. Families see the squeaky clean codes on TV and think it will be the same. How wrong they are. I believe that if they really truly knew what kind of damage we do during a code, they might change their mind.

I joke when I hit about 80 (or get a terminal disease...) I'm getting DNR tattooed right on my chest (except I guess that really doesn't work, but it's a good thought!).

Penny Mitchell said...

And they will never know the toll it took on YOU, never mention the toll it took on Grandpa.

I am insanely proud that all I insisted the staff do for my Mom exactly two weeks ago was keep her morphine on time. I did her mouth care myself. We repositioned her. We talked to her. We sang to her. We didn't have any cocktails, but we basically had a party going in her room, with the staffers present who had come to really, truly love her. And when she wanted to go, she went. We didn't beat another few minutes or hours or days out of her.

Good God. I hope Grandpa's family has learned to live with this, and learned FROM it.

Gotta go bawl now.

shrimplate said...

Too bad about all that HIPPA happy hooha or we could shoot video of codes like this and post them on YouTube.

These are things, like returning coffins, that many people really need to see.

SClubBethan said...

I completly agree. I work with people with dementia and and most of our patients are DNR, but there are the few whose family refuse and we have to go through the indignity of breaking the ribs of the 85 year old lady. If we do get a pulse back they get she'll plesure of moving to a general ward where she gets to die in an unfamiliar environment a few hours later. Worth it?

marachne said...

A couple things I try to do to impress the futility on people. I phrase the DNR question as "if someone comes into your room and you are dead, do you want us to shock you and push on your chest to try and get your heart started again? (similar script for family members). I don't generally talk about "breaking ribs" unless they have metastatic cancer b/c I think that people then just think you're being overly dramatic.

Also, if/when appropriate, I point out that the survival statistics from an in-hospital code is around 15%, while the survival to discharge is about 6%...and for older adults or those with cancer is even worse.

We need to be talking to patients and their families in a realistic way, but it's a fine line...

Anonymous said...

Uggggggg just reading this post made depressed.

Mz.Elle said...

Thank YOU!
My father in law had a heart attack,had surgery, recovered and has been alive and kicking for 6 years now BUT he knows his time is
coming and he has instructed all of us to just leave him be should
he have another. In fact,Mum is under strict orders to not call for an ambulance until she's sure he's d.e.a.d dead. They've seen
the after effects of what you witness,with loved ones many times
and are surpisingly realistic.

We talk about it all the time amongst ourselves and with our own kids. We want them to know our wishes too. I think I may just stick your post on my fridge;p

Anonymous said...

Thanks for this, Jo. I have forwarded this story to my family members and friends (yes, they'll think I'm morbid but I don't care). I've let them know to DNR me please and thanks. You have performed an important service for your readers - wish I could get the word out to more people about this.

Joy K. said...

I've not been in the position to witness scenes like this. How open are medical personnel with families concerning the inevitability of the death?

Jo said...

Joy, the folks I work with are very honest with families. We nurses have the wherewithal to talk about DNRs with families, and we do. I've not yet heard a doctor offer false hope to a family, and most of them are quite blunt.

But honestly? What drives a person to not no-code a family member is guilt. There's not a lot we can do about that...and it might be better in the long run for the survivors to know that they did everything they could. I don't know.

My sympathies here tend to be more with the dying, admittedly, than with the living. I figure you have X number of years in which to redeem yourself if you're still alive, but you only get to die *once*, and that should be as stress-free as possible.

girl_in_greenwood said...

Word. Me and bunch of other new nurses were talking about this at lunch today... one of us had seen one of their patients coded and found it traumatic. The patient was 94 years old with a bad heart. Their POLST form said Do Not Intubate, CPR only. But in the heat of the moment, when the docs said to the patient's child, "can we intubate your parent?" they said yes. Not that it made a difference, obviously. So sad! A 94-year-old deserves a better death than that! But it seems like families believe the TV codes are like the real thing, and that their loved one will wake up and be fine afterwards.

Anonymous said...

My grandfather had a massive stroke a year and a half ago. They kept him technically alive long enough to get him to the hospital and hook him up to a bunch of machines to keep him going, but really, he was gone as soon as he hit the floor.

My mother's cousin refuses to speak to us now because we wanted him removed from the machines, no code, just keep him on oxygen and let him go. He died within a couple of days, just stopped breathing in the middle of the night.

She's still furious that we "let him die." Part of me really wants to print this out and ask if this is what she wanted for him. There was NO CHANCE he would recover AT ALL. He was also eighty-four years old and had lost his wife eight years earlier - he was never the same after that and in the weeks before he died, you could tell he was missing her more than ever. He made me promise to take care of his grave. He was ready to go long before he went.

I'm not sorry for that decision (I'm sorry he's gone, because he was a great person and I miss him, but everyone dies). I wish this post would be read by everyone with elderly relatives.

Anonymous said...

I just recently started in ICU, finishing up my ccnp course. I have seen my share of codes, much to your description, it isn't pretty, and i think people need the harsh reality of just what happens. TV softens what happens, doesn't show the ribs cracking, the shocking or the after effects. Grandpa may suffer several infarcts to the brain and be quite vegetative. But heaven forbid you don't give all to resucitate. It's part of life, death. There's a time to let go, and i think people should be aware of what happens during a "code", no matter how hard it is to accept.


Tony Heywood said...

Thats was a really interesting post, I am sure that the grief and the fear makes people want to squeeze the last drops of life into a loved one.

I am sure I don't want that happening to me.

Thats and interesting post. I will be back to read more on your blog. If you come to London and are looking for somewhere to see client you should visit Knaresborough Place -
Medical Rooms London

judycolby said...

My dad had a heart attack a few years after my mom died. He coded (is that the correct word?) while in the hospital and they brought him back. Hid did not have a DNR.
It was suggested by the doctor that my sister, who lives close to Dad and sees him daily, learn CPR. She said "Not me, I'm not bringing him back, he wasn't real happy about it this time."
He now has a DNR and we all have copies. He would never hasten his death but he is ready to go when the Lord is ready to take him.
Interesting topic.

John said...

Wow. This is a powerful post.