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Ethics question

Discussion in 'Medical Students - DO' started by spat, Apr 17, 1999.

  1. spat

    spat Junior Member

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    What are everyones thoughts on slow codes: A slow code is a unwritten rule that the medical doctors says move slow because the patient is pretty much dead or going to die but the family still wanting everything done for the patient. The family will not make the patient a no code. Theoretically one would say if the family wants everything done for the patient then it should be done. For example an end stage cancer patient and the family wants the doctors to do everything they can for them. They have coded several times already and with a little epi that heart just keeps coming back.
     
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  3. Gregory Gulick

    Gregory Gulick Senior Member
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    Terrific question, Spat. I might argue that it is unethical on the grounds that it violates a patient's right to self-determination and violates the trust of the physician/patient relationship. But I do understand why it happens. In some cases, I imagine it is because physicians don?t value the patient (as in the case of an elderly patient). In other cases, I would suspect that the health care professionals just do not want to resuscitate a patient that, they feel, will undergo more damage in the process (i.e., breaking of ribs during chest compressions) than derive benefit. Carrying out such resuscitations probably weigh heavy on the hearts and minds of the professional. So in some cases the intentions are good, but it doesn?t make the act any less unethical or excusable.

    To put things in perspective, I wanted to find some data on how often health care professionals perform slow codes. I found the following ethics survey of nurses (1998: n=2000; 1988: n=743). It provides percentages of nurses who have been involved in slow, senseless, or partial codes. Spat already defined slow codes, so I don't need to explain that. A senseless code, however, is a code that the health care provider feels, in their opinion, should NOT be taking place. And a partial code is situation wherein a patient has specified that only certain aspects of resuscitation should be implemented (i.e., defib but no chest compressions).

    Here's the data. And I must admit, the numbers are somewhat higher than I originally expected:

    [​IMG]

    (The "*" implies that there are other medical specialities included in this group).

    I hope this puts the topic in perspective. It does happen, and apparently, quite often (especially in the emergency rooms).

    Comments?

    [​IMG]


    [This message has been edited by Gregory Gulick (edited April 18, 1999).]
     
  4. UHS2002

    UHS2002 Senior Member
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    Gregory,

    thanks for the numbers, they are very interesting. It is a subjective survey, of course, because it reflects the participants' view of what a "senseless" code is.

    I have participated in and run many codes in my former career and I can attest to the fact that "senseless code" is a VERY subjective judgement. I have even seen major fights break out at the scene of a code over this issue.

    I understand what you are saying about no valuing elderly patients and there is some of it around. However, I think the main consideration is that, coding a person with multiple serious illnesses, at least one of which is terminal, and be successfull just to see this person being released to a nursing home with brain damage or ventilator dependent, or not being released at all, seem a cruel endevour to many people, me included.

    So you have a patient that is in the end stages of CHF. They are not comfortable, because it is hard to breath when you have a fish tank in your lungs. Diuretics are good, up to a point, you just can't shrivel them up to a prune. So they are on morphine, because it keeps their discomfort down to a manageable level (someone trashing about due to hypoxia, isn't a fun thing for anyone concerned, much less the patient). Well, they code. They have no DNR and you are in the ICU, so their down time is minimal. Do you go all out and work a full code??? An instructor of mine used to say that "gime me enough and I will get a heart rythm out of barn door". So now you have been successfull (doubtfull, but it does happen) and the patient has a heart beat again. If they are lucky they are also spontaneously breathing. Their heart isn't any stronger and there are still gold fish planning on moving into their lungs... They are probably zonked out on the morphine, so they have little awarness of what is going on. But you did respect their wishes and "didn't violate their right to self determination" and the "trust of the patient/physician relationship". WOW, I am impressed!!!! Unfortunately, perhaps this wasn't even a patient of yours to begin with, you just happen to be on the code team that shift, or perhaps if that person knew the condition they would be in they would have signed a DNR a long time ago. Unfortunately, most people outside the health care field have only a tenuous idea of how exquisitely our current medical technology can prolong their dying... And 80 year olds are not good candidates for heart transplant...

    Personally, I have a clean legal conscience. I have always fully coded patients without DNR unless they had been dead so long that they exhibited rigor mortis. It is the law. I have always worked as fast and as completely on the patients that I personally thought had a chance and on those I thought "why try?!". Why??? Perhaps because I have a strong adversion for playing divinity-in-charge and also mostly for selfish reasons: it is great practice, you know?! It beats intubating a dummy, and you keep your skills up. Thankfully, I have never been able to successfully code anyone who was down too long. I think I would have felt terribly guilty for the pain I would have helped cause, even if it was "their choice to be coded".

    CPR will break ribs in most adults, no matter what their prior health condition was. Nobody I know ever though that breaking someone ribs in the process was a big deal, so I dont think it factors highly in the equation. Everyone is more concerned about the brain than the ribs.

    I think "unethical" is a very strong word and you give the impression, in your post, that you categorically think that it is a black and white situation: the person has a DNR, then it is OK not to code, they don't have a DNR then we all have to go full steam and code them. I am curious to know, and truly NO offense meant, in how many codes you were a team member or how many codes did you run?
     
  5. Gregory Gulick

    Gregory Gulick Senior Member
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    UHS2002, no offense taken of course and thanks for the response.

    You must have misunderstood the intent of my message: Spat presented an ethics question, so I gave an ethics response. No ethical issue is black or white. Unethical practices go on everyday in every profession. They are really ideals to aspire to, not laws to adhere to. So saying that something is unethical or not ethically justifiable is different from saying that something is wrong or illegal.

    And of course, I've not been on any code team. However, this doesn't disqualify me from providing the ethical arguments for or against the process and I doubt that many professional bioethicists (Ph.D.s) have been on any code teams either. Having a long-standing interest in ethics from my graduate studies in gerontology, I provided this discussion with the ethical arguments against slow codes: physician/patient trust and personal self-determination (autonomy). In fact, I just did a quick bioethics internet search on the subject and found that the bioethics department at the University of Washington School of Medicine tends to offer the same arguments I did:

    It is the policy of the UWMC, Harborview and VA that so-called "slow-codes," in which a half-hearted effort at resuscitation is made, are not ethically justified. These undermine the right patients have to be involved in inpatient clinical decisions, and violates the trust patients have in us to give our full effort. Source: eduserv.hscer.washington.edu/bioethics/topics/dnr.html

    Furthermore, I just consulted the text Principles of Geriatric Medicine and Gerontology (realize that I am a gerontology graduate student, so this is obviously the perspective from which I operate) and it states:

    Discussions regarding CPR should focus on whether it serves the patient's goals, and such discussions should be repeated at various stages of health because patient values may change. Partial codes are appropriate only when they reflect the wishes of the patient or surrogate and do not violate rational use of elements within CPR. Slow codes are not ethically justifiable.

    So again, I certainly don't feel that this is a black and white issue and I am not discussing right and wrong. I don't know what your background is in ethics, but there is a certain way to present and argue ethical dilemmas using autonomy, beneficence, nonmaleficence, justice, etc. and this is what I did. This is much different from presenting my opinions or feelings on the issue and, in fact, these are generally excluded from ethical discussions.

    And lastly, I certainly won't question anyone's real-world experiences or decisions they made because I appreciate that ethics get fuzzy in real-life situations and are difficult to adhere to.

    I do hope someone will present an argument of how slow-codes are ethically justifiable (using ethical reasoning, of course). I'm sure one exists, I just couldn't think of one.

    Good luck to you!

    [​IMG]

    [This message has been edited by Gregory Gulick (edited April 19, 1999).]
     
  6. OldManDave

    OldManDave Fossil Bouncer Emeritus
    Moderator Emeritus 10+ Year Member

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    Boy, did you open an ENTIRE CASE OF WORM CANS!!!!!

    Well, my perspective in one that is torn between legal definitions of ethical and legal and my own personal experiences. I have been in on more codes, both slow and frantic, than I could ever count or remember. I have over 9 years of peds-ICU and peds ER/Truama experience.

    All of the points above are valid and significant; but I want to touch on a different angle. Just because we are capable of doing something, should we? I know, this seems like a rather innocuous question...but trust me, it isn't!

    First, let me state, there are things far worse than death...far far worse. My first year of ICU was in a burn center. We got most of them thru the burn trauma only to loose them 2~4 months later to overwhelming sepsis or something that looked like bread-mold growing on a leg.

    I have seen children and adults 'survive' devastating illnesses only to become vent dependent residents of some ward. Only to waste away and die alone. You know, all too often these people's, or what's left of them, only companions end up being the people who work where in the nursing homes they exist in. The friends and family who were so adamant that everything be done are generally shocked at what is left of their loved one. They end-up abandoning or orphaning the patient bacause they don't understand.

    In the family's defense...they really did not know or could even fathom what the possible outcomes were. You know, to them the worst possible outcome for Grand-ma was if she died. They have no concept of what it's like to see a neurologically devastated vent-dependent Grand-ma who lives in vent ward #3. It's a natural human instinct to begin distancing yourself from things that are so severely painful. I mean hell, on TV..the patient either dies or walks out good-as-new. These are the extremes of the continuum...and not always the reality.

    For me, it all boils down to we have yet to figure out how to factor in things such as quailty of life and should we? In and of itself, those two questions should strike terror in your heart!! All of the sudden,in taking these 'humanity issues'into consideration; you're placing yourself into the judgement seat...a place no human is truly capable serving.

    On the other hand, many things that are now routinely repairable would not have become so if physicians had not pushed the envelope.

    Just because we can, should we?

    In essence, I don't know the answers...and anyone who professes to know them has obviously never been in the position of doing compressions on a child while it's parents watch the light of their life die, while you do your damnest to prevent it.

    Unfortunately, it is a position we will be in one day...probably the hardest one we will ever be in.



    ------------------
    'Old Man Dave'
    KCOM, Class of '03
     
  7. OsteoDOC

    OsteoDOC Member
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    As Dave has so nicely put it, "have you opened up a can of worms."

    I am going to infer from UHS2002's post that he/she was probably a paramedic in his/her former life. If that is true, then we both have had the same job (I still continue working as a paramedic for 5 more weeks until I graduate from medical school..after 10 years of it I have had enough). But, I don't think that someone has to have run a code to look at the ethical point of view or much less the legal point of view. I feel that anyone can voice their opinion based on their own feelings and as Greg has said, it is not a black or white issue.

    I don't think there is a universal "right" or "wrong" answer to that question. I think that the correct answer is up to the individual patient. Unfortunately, as Dave has pointed out, many times the family of the patient is making the decision based on ignorance or their own fears..i.e. death is the worse case. I, like many others, have seen what happens if you work a code only to have basic functions retained but no any mental capacity. The trouble is, no one ALWAYS knows what the outcomes will be. Some one has to make a decision and it is usually the physician. that is just part of his duties..one that is not always well liked.

    I feel that everyone has to decide for themselves what they are going to do when faced with that decision. I personally don't feel we should work EVERY at ALL costs. I work a 40 year code much more aggressively than an 80 year old code, all things being equal. Most statistics support that but that doesn't always go over well with everyone. I have heard someone accuse me of "playing God". My response to that is "God spoke the minute that patient's heart stopped..and I had nothing to do with it. Now, trying to resuscitate someone is may be playing God." Just MY point of view.

    Dave made a VERY valid point, "just because we can do something, should we?" That is something EVERYONE should think about, whether they are in the medical field or not.

    Just my opinion. BTW, the higher case is just for emphasis not yelling.

    Brandon A, MS4
    Western University/COMP
     

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