sorry, I don't feel the goal should be to give people a dose of reality to get them to stop resuscitative efforts or manipulate families to do what we think best, especially when this dose of reality is catching a snapshot of their loved one dying
I believe resuscitative efforts should be for the benefit of the patient, or, if the patient is too far gone for it to be of benefit to them and they are likely not suffering from a futile code, than to benefit the dead patient by proxy to their family members
I see having them there as a way to try to bring closure, in hopeless codes to offer the sense of "everything was done" "we didn't give up" "it was just their time." The times we had family there I found was more fulfilling for everyone involved - from family to doc to chaplain to nurse.
Admittedly, codes are frustrating when the result is a veggie on a vent, that outcome I think should attempt to be prevented if it seems likely far before a code happens, with patient & family education (yes this is best case and doesn't always happen) to get a DNR, because it makes objective medical sense without casting judgements about acceptable QOL and it is in line with the values of the patient.
However, if the likely outcome of a code is death AND a DNR was not able to be obtained, than I see no reason not to do a code and allow a family to be there if it may be of psychological benefit. You could quote financial and emotional costs to the team, sure.
Providers, palliative care, social workers, and chaplains can often discuss with a family to explore if being present for a code will have more or less positive impact emotionally overall.
We had one code that got crazy bloody and the family was escorted out, and brought back in when the code ended after we made things more "presentable"
My hospital's policy was based on studies that showed families preferred the option and that those who chose to be present generally reported satisfaction with that choice. They were also sure to have someone attending the family present, such as a nurse or ideally chaplain, to keep everyone safe and as comfortable as possible
JFC, it's not all about getting your DNR orders and getting out of futile codes or pushing people with one foot into the grave into it just because you think they should be there, or you think they have an atrocious quality of life, or a short life, if they can express they want to live despite those things.
I had a very young patient with cancer and probably 6 mo to live, that otherwise and being young, likely would have bounced back well from a code. And everyone acted so put out that so much effort in the hospitalization was taking place for them, and even moreso that we might be faced with the work of a code. Like how dare this person not be DNR. Like 6 mos of life shouldn't be worth a ****ing code to this patient. This person was holding their spouse's hand and telling me about their 2 young kids ffs, and how their goal was just 3 more months to have a last birthday with the kid. If a code had a decent chance of giving this person a shot at even 6 more days as they were with their family, who the **** am I to decide that amount of time wasn't worth my trouble???
I can think of other times with patients that had cognitive deficits from stroke or whatever, with atrocious QOL, yet definitely capable of expressing wanting another day of life. If the code can't do that, I tell them so. If it might, I don't begrudge them full code.
These are loved one's dying before people's eyes from the admit to the declaration of death.
I was present when my own parent took their very last breath in the ICU. I have some pretty ****ing strong feelings on how every single person involved in the care of someone circling the drain should act.
1) Most physicians don't make it clear enough that code status, whether it's full or DNR, has NO bearing on how hard we work to obtain the goals of care prior to that event. That is a huge fear, that if the patient agrees DNR over code, that all the providers stop caring as much and don't work as hard to prevent the code. I hate to say that I think there's some truth to this, actually. However, in my prior code discussions, I gave my own word that would not be the case, and I like to think by doing so I did in fact try to live up to my word. In reality, code status should not affect treatment while the patient is alive except where it makes medical sense. (sometimes patients that are DNI vs full code have to be handed differently re: respiratory distress)
2) Trying to scare patients by telling them about rib breaking is just stupid in my opinion. Why would that dissuade the person who wants to live and expects a code to bring them back to life just as they are? If you thought rib breaking was the difference between life as you know it now, and death, what would you choose? NOGAF about rib breaking. Just another case where physicians are not thinking like patients.
3) Ditto with telling people about tubes and vents. Aside from fear of never coming off machines, no one cares. Everyone that wants to live wants to live. People have watched too many tv shows with people with a tube taped to their mouth, and they live. So no, intubation doesn't scare most folks.
4) Here's the bottom line what patients care about:
"Can the code bring me back to life?"
"Well, technically yes, but it's extremely unlikely, and we'd have to tube you, put you on a machine, and break your ribs. You might never get off the machine."
"Can't you just turn off the machine and let me go if it all don't work?"
"Well, yes, but that can be complicated."
"What are the odds?" (if you don't say zero, they won't care)
"1 in a million."
Patient: "I'll take my odds!!"
5) Here's the real bottom line, and what patients care about and need to know. It's not that they may suffer from the code. It's not that they may die despite the code. It's the fact they might not come back the same, and that taking them off the machines isn't always an off button, abort, this didn't work like we hoped.
THAT is the part, THAT is the real risk that frankly matters to most people. (I privately call it the "vegetable risk")
If I have a code discussion, that is the part we talk about.
What is their threshold for taking that risk, that they do come back but only on machines, or they don't come back the same way off the machines, and are stuck like that?
Some people are more or less likely to bounce back well from a code.
Without getting my personal feelings involved, I try to give as objective a medical opinion as I can, based on the patient's situation, of what might happen, noting that I cannot really predict it. Not based on my perceived quality of their life, or how long they may have to live. I might suggest they take into account how long they have to live, how they feel now, and how acceptable they feel the risk of a bad code outcome is, into their decision.
6) In my hospital, the code status order includes like 6 different checkboxes. Almost all patients of mine ended up partial code. Why? Because if I can rescue someone who WANTS to be rescued with bipap, I'll do it. It's a no brainer a lot of the time. Same with some of the other things. There's cardiopulmonary arrest, and then there's everything before that. It's worth thinking about those things in the context of THAT patient.
My final thoughts are, that my goal is never about a certain outcome I want. My goal is to find out what future my patients are hoping for, and then educate them on how likely we might be to get there/not get there, and what that might take.
I would never use the events mid-code in some sort of attempt to "educate" the family or get them to change code status. If that discussion needs to happen, someone on the team capable of both explaining the medical realities, likely outcomes, and can elicit patient/family values, should do so in an environment conducive to that discussion, likely away from the code. Because while compressions are taking place there is time to attempt such a discussion, if only briefly.
TLDR:
Please no personal attacks. If you want to tell people my thoughts here were crap, that's fine.
I just realized today is the anniversary of my parent's passing after writing this.
I know I rant a lot but this rant had more meaning than I thought when I started.
Now that I've written it all I don't have the heart to delete it. This isn't a bid for sympathy. Just carry on.
