code blog: tales of a nurse

My last post was about what happens when we withdraw treatment from patients. This post will be about not withdrawing treatment.

There have been many medical advances which have allowed us to learn to get patients through the very serious part of some illnesses with their lives. Sometimes a pneumonia just gets ahead of someone quickly and the "bugs" enter their bloodstream and they go "septic." The patient was active before the illness, and there's a good chance they'll be active after the illness, provided we can successfully treat them and the sequelae.

But some patients are wallowing in nursing homes, not being very active or even very verbal. Yet their friend pneumonia shows up to take them peacefully to the other side, and we wrench them violently back with vasopressors, postive pressure ventilation masks, ventilators, antibiotics. Then if that treatment is only partially successful and the patient has not made a full recovery, we flog them some more with permanent feeding tubes and/or tracheostomies.

We recently had 2 patients who were completely ridiculous ICU admissions. I'm not saying they were riduculous hospital admissions, just Intensive Care Unit ones. One was a 90+ year old woman who was intubated and put on a ventilator. An artery feeding the lower half of her body partially clotted off and left her legs bluish and very painful. No surgeon would take her to surgery to fix it - she was an AWFUL surgical candidate. She could not eat, so we fed her intravenously. As if this weren't bad enough, she was a full code for about a week there - if her heart had stopped, we would have had to do compressions and defibrillation.

Every doctor possible was eventually consulted for her case. The family wanted EVERYTHING done, even dialysis. In my very soul, I felt as though we were criminally assaulting this woman. We never did get to dialysis, and we finally made her a "no code." She passed away a couple of weeks after her admission surrounded by a family with questionable motives and in horrible pain. What this woman needed from the get-go was a morphine drip and some peace.

The other admission made me so angry. It was an 80+ year old man with severe dementia who was admitted with pneumonia. Although he was designated a "no code/active care," he still bought a bed in ICU. Active care means antibiotics, IV fluids, supplemental oxygen. The "no code" part means that if his heart had stopped or if he stopped breathing, we would have done nothing to resuscitate him. Antibiotics, IV fluids, and oxygen are things that a general medical floor can handle with ease. Instead, he took up a bed in my exceptionally busy ICU.

I don't mean to sound callous, like he was wasting our time... He was certainly an appropriate hospital admission, but not an ICU admission! And even though he was a no code, when he started to decompensate, his nurse still considered doing more and more to "save" him! I understand that death of a loved one is painful for the people left behind, but can someone please tell me the point of trying to save someone severly demented, unable to care for themselves? I can say with 100% certainty that not only would I choose to just make my own mother comfortable in that case, I would be horrified to have her flogged in an ICU with uncomfortable oxygen masks and restraints.

Some people never even really recover from pneumonia, even if they were playing 18 holes twice a week. I'm not sure if the general public thinks we can cure everything these days or what. The human body MUST be able to heal itself somewhat. Nothing we do ever actually helps the body heal - the interventions we provide merely get the human body through the storm. "Supportive care," it's called. Sometimes it works, sometimes it doesn't. I've even seen people younger than 40 succumb to exceptionally bad pneumonia despite every single high-tech intervention imaginable. Of course I guess I could say that antibiotics help heal the body, but multiple antibiotics can also cause antibiotic resistance, superimposed infections (fungal infections that crop up because we've killed off the "good" bacteria as well as the bad) and contributes to drug reactions/interactions.

I know I've ranted about this sort of thing before, but it's my pet cause. It breaks my heart to have to do the things I have to do to people I know won't get better. Don't think for a second that I don't follow orders I consider to be excessive - my job is to do that regardless of my personal beliefs. But it is also my job to educate people about the limitations of what we can do. Sometimes it's hard for the family to step back from the situation. It becomes a mentality of "beat this at all costs," like it's some sort of challenge that must be won. That's understandable in some cases.

Recently, we had a 60ish year old patient who we were trying really hard to save - we used every treatment we could possibly come up with. Unfortunately, he had a major setback and we started to address code status with the family. They maintained that they still wanted everything done, despite our predictions that he would code very soon. We thoroughly explained every possible code intervention - compressions to defibrillation, and the family wanted it all. When it was looking like he would code within an hour or two, his nurse brought the crash cart into the room, put the patient onto the backboard for CPR, stuck the defib patches to the patient and hooked them up to the powered-up defibrillator. In addition to the ventilator and the continuous dialysis machine, the defibrillator was beeping with every heartbeat.

Although we had already explained each of these procedures in detail, the family was horrified to actually see the equipment fired up and ready to go. The nurse explained what everything was for, and what it would do, and the family immediately said that we would be doing none of it. We removed the crash cart from the room, but continued with the ventilator and dialysis machines. About an hour later, the patient's heart rate slowed and then stopped. The family was all there and although it wasn't the most peaceful death with the machines still around, it was better than having an electric shock and someone pounding on his chest.

The nurse made the right call with that particular family. He'd already had a good relationship with them and it's a 100% certainty that the patient would NOT have survived. I can't help but to think that we somehow imposed our beliefs... but we also advocated for the patient.... for his right to have the best death possible. It's a pretty difficult position to be in.