Futile Codes

[docB]

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Three times in the last 48 hours I've gone to codes in the ICU where the patients were vented and on 3 or more pressors all maxed out. One was actually about to go for a cerebral blood flow study to see if they were brain dead. Yet these patients were all still "full code" when I was called. In each case I pretty much just checked the tube and called the code when I arrived as they had usually gotten 1 or 2 rounds of drugs by the time I got there.

I'm used to futility but this is just too much. Is there ever any benefit or survival when coding someone who is maxed out on multiple pressors? There should be a rule that if you're maxed out and you code that's it.

 

[DoctorMedic]

agreed

 

[beanbean]

I can completely understand a family clinging to the hope that their loved one is "strong" and will 'pull through this", but sometimes reality fails these people. On my ICU month we had a very sad case of a woman in her 50's with an inoperable meningioma - she had been a surgical candidate 8 years ago but had declined surgery. The tumor was now HUGE and she was in the step-down unit for ~2weeks. She was unresponsive, with unequal pupils and would posture when deep suctioned. Despite the ICU team, palliative care, ethics and the rest of the family trying to talk some sense in to the daughter who held the health care proxy, this poor woman remained full code. Of course the daughter would rarely come in to visit as it was "too disturbing" to see her mother in this conditon. She also would request that no one use the word "death" when speaking to her. Finally, the daughter stated she didn't want CPR done, because she didn't want us to break her mom's ribs, but intubation was still a full go. Fortunately, when she went into respiratory failure she also went into cardiac arrest and did not have to languish on a ventilator for weeks.

 

[southerndoc]

I stop all pressors during a code. There's nothing in ACLS about administering infusions of pressors for asystole, vfib, or PEA. If I get a rhythm back and they need the pressor, then I'll restart it.

 

[Stitch]

When I was a resident, we had a kid with pretty bad osteogenesis imperfecta. His mom took great care of him, but he was still pretty gorked. When he came into the unit one time, she tried to insist we give him CPR should he need it. The intensivists basically refused on the basis that CPR would just kill him anyway. She was furious.

My hospital is starting to let families come in and watch codes, but mainly in the unit. They've had 'good' experiences driving home the point of how sick their loved one is. I haven't tried this in the ER. Anyone have experience?

 

[GeneralVeers]

When I was a resident, we had a kid with pretty bad osteogenesis imperfecta. His mom took great care of him, but he was still pretty gorked. When he came into the unit one time, she tried to insist we give him CPR should he need it. The intensivists basically refused on the basis that CPR would just kill him anyway. She was furious.

My hospital is starting to let families come in and watch codes, but mainly in the unit. They've had 'good' experiences driving home the point of how sick their loved one is. I haven't tried this in the ER. Anyone have experience?

The code situation is one of the few where we as physicians can actually do the the right thing for the patient and declare medical futility.

If they are elderly with multiple medical problems and are brought in by ambulance, I will code them just enough to get them on monitor, give 1 set of epinephrine, and a cardiac U/S. After that I call it.

The ones I hate are the ones who respond weakly to epi. You'll code them, give a round of epi and get a weak pulse back, which will typically fade back to asystole in 3-5 minutes, often before the dopamine can even be started. After three rounds of epi, I typically withhold any more meds and call it.

 

[Stitch]

The ones I hate are the ones who respond weakly to epi. You'll code them, give a round of epi and get a weak pulse back, which will typically fade back to asystole in 3-5 minutes, often before the dopamine can even be started. After three rounds of epi, I typically withhold any more meds and call it.

Do you use epi drips much in adults?

The ones that come in dead, I will go through some motions for the family, maybe a round of epi and 1/kg of bicarb (I know there's no data to support it). I've found having the ultrasound there to show the parents the heart isn't beating helps a lot.

 

[GeneralVeers]

Do you use epi drips much in adults?

The ones that come in dead, I will go through some motions for the family, maybe a round of epi and 1/kg of bicarb (I know there's no data to support it). I've found having the ultrasound there to show the parents the heart isn't beating helps a lot.

I rarely use it. If they're going to be on an epi-rip (meaning Dopamine isn't enough) then the survival is unlikely.

I had one lady the called me for a code in the ICU. She had a coagulopathy probably from DIC and she was bleeding out of the ETT, into her lungs, into the foley. She kept going into asystole. Family was standing by and wanted "everything done". She was one of the ones who responded to epi, and would transiently get a pulse for 1-2 minutes after each bolus. Finally I stopped the epi and called it. Sure I probably could have kept her heart beating for several hours, but would the outcome have been different? There are certain cases where it's clear to everyone involved that every effort will be futile.

 

[dchristismi]

I pull the family in for codes in the ED whenever I can exactly for those reasons - the family can see exactly what we're doing, that there are 20 people rushing around and there is chaos and blood and pain and sweat.

And I have to admit selfishly, that it makes "the talk" go a lot easier.

I have had many families thank me for showing them that we "did everything" (even if it was just a round of drugs, the cardiac u/s, and letting them hold their loved one's hand as I call it.) Many times, they will be on the phone with the rest of the family giving play-by-play and they often will comment that the patient is gone before it's over.

And on the rare occasion I get someone back, they seem to understand how violent it is, and often will make the patient a DNR.

 

[Dwindlin]

Long as family was calm I used to have them watch pre-hospital codes and try to park a well seasoned EMT with them to answer questions.

 

[AmoryBlaine]

I have refused to do chest compressions. The poor patient was like 90, had several strokes, and EF of 15%, MSOF, 4 pressors from sepsis and arrested. The family wanted everything done. I ended up doing like 10 compressions on her feeling ribs pop with every 2nd pump and just said, "I'm done."

I think we need to do a better job of educating. I know we try but I think more docs need to use the words "dying" and "death" more frequently. For us to indulge unrealistic family wishes is unfair to us, the patient, the family, and the hospital.

I would think that there could be some score, perhaps like APACHE II, at which point CPR would be considered battery. Chest compressions would not be ethical on a patient with a sprained ankle, they probably have no more benefit for the patients we are talking about...

 

[roja]

As long as family is calm and noninvasive, I have them in the room if they want.

I often invoke medical futility when it is deemed futile. I have had to deal with this in my own family as well. So, I am familiar with both sides. The family needs to hear that there is nothing left that can be medically done to save thier family member. A sincere apology and firm stance is important. Answering questions is also important. most people don't want thier family member to die. That doesn't mean you have to torture a patient or anyone else when it is truly futile. my .02

 

[akomark]

I have refused to do chest compressions. The poor patient was like 90, had several strokes, and EF of 15%, MSOF, 4 pressors from sepsis and arrested. The family wanted everything done. I ended up doing like 10 compressions on her feeling ribs pop with every 2nd pump and just said, "I'm done."

I think we need to do a better job of educating. I know we try but I think more docs need to use the words "dying" and "death" more frequently. For us to indulge unrealistic family wishes is unfair to us, the patient, the family, and the hospital.

I would think that there could be some score, perhaps like APACHE II, at which point CPR would be considered battery. Chest compressions would not be ethical on a patient with a sprained ankle, they probably have no more benefit for the patients we are talking about...

Refusing to perform CPR on a full code patient when you are the resident and not the responsible attending physician is a pretty cavalier move. None of us like it, but at our stage of the game, and our level of responsibility for what happens to this pt (far, far below that of the attending staff physician), this is not our decision to make. Just get to that chest and start pressing.

I think one of the big problems is not enough of the PCP's out there are having discussions w their pt's regarding code status, and then documenting these discussions. Every pt over the age of 80 who regularly sees primary care should have this discussion w their primary doc, and the doctor needs to document this in the chart. The ER visit for Grandpa Joe when he is brought in in PEA, brought back and then goes PEA again after his family arrives is not the time or place for this discussion to be had for the first time. One of the problems w good CPR is that sometimes it actually works...and how are we to expect a family who has just gotten to the ER and seen grandpa revived by the ER doing ACLS to then say, you know what, you guys are right, if he codes again you probably should just let him go. Not gonna happen. We had a case not too long ago where a 91yo dialysis pt w hemorrhagic brain mets on his CT scan coded on the CT table...we tube him and start coding him, he comes back, w/in 15min he's PEA again, he comes back (this scene keeps repeating itself, all told he had about 85min of ACLS performed on him), and the whole while our staff is explaining to the family how futile this process is and the only thing they are focused is on is how he keeps coming back so surely whatever you guys are doing is working.

Anyway, point being the ER is about the worst place in the world to be having the code status discussion and PCP-land is where this stuff should be happening.

 

[emtcsmith]

In the prehospital setting my partner and I see about five codes a month. We've agreed that we work any codes that there are not obvious signs of death, and if after "three rounds" the patient continues to be in asystole we'll call for field termination. Now if something changes, codes in public, younger, etc then they have to be transported. In the field terminations we've done we haven't had any issues with the family.

I had to bring in a elderly code last week because every so often she'd have what looked like a PEA and I couldn't be sure I couldn't feel a pulse on scene. I feel the pain of futile codes but its part of the job.

 

[EdibleEgg]

Refusing to perform CPR on a full code patient when you are the resident and not the responsible attending physician is a pretty cavalier move. None of us like it, but at our stage of the game, and our level of responsibility for what happens to this pt (far, far below that of the attending staff physician), this is not our decision to make. Just get to that chest and start pressing.

I think one of the big problems is not enough of the PCP's out there are having discussions w their pt's regarding code status, and then documenting these discussions. Every pt over the age of 80 who regularly sees primary care should have this discussion w their primary doc, and the doctor needs to document this in the chart. The ER visit for Grandpa Joe when he is brought in in PEA, brought back and then goes PEA again after his family arrives is not the time or place for this discussion to be had for the first time. One of the problems w good CPR is that sometimes it actually works...and how are we to expect a family who has just gotten to the ER and seen grandpa revived by the ER doing ACLS to then say, you know what, you guys are right, if he codes again you probably should just let him go. Not gonna happen. We had a case not too long ago where a 91yo dialysis pt w hemorrhagic brain mets on his CT scan coded on the CT table...we tube him and start coding him, he comes back, w/in 15min he's PEA again, he comes back (this scene keeps repeating itself, all told he had about 85min of ACLS performed on him), and the whole while our staff is explaining to the family how futile this process is and the only thing they are focused is on is how he keeps coming back so surely whatever you guys are doing is working.

Anyway, point being the ER is about the worst place in the world to be having the code status discussion and PCP-land is where this stuff should be happening.

I agree that "PCP land" is by far a better place for discussion of end of life issues. In an ideal world, you guys would not be involved at all and great grandma could have a peaceful death at home. However, our society has an unique and somewhat problematic view on the dying process. I have discussion about end of life care with every patient over 60, every hospital admission, and every nursing home patient. I explain the dismal statistics for return to meaningful life after cardiac arrest; I talk to families. However, I'm not convinced that my time really changes much. There are deep beliefs about the abilty and intent of our health care system that are not easily changed by a brief discussion. Could PCP's do a better job? Yes. Would spending an hour on this discussion with every patient change much? I'm not sure, but I think it mostly just gives me a better understanding of what the patient wanted in the first place.

 

[DoctorMedic]

even discussions and DNR's won't always help, i have been called to countless cardiac arrests where the healthcare proxy has recinded a DNR on scene, or just called becaues they didn't know what to do or who else to call. Also the funeral homes are good at telling them to call 9-1-1 for some reason. Either way those I will work up to 3 rounds and call for termination if no obv signs of death.

 

[docB]

I feel the pain of futile codes but its part of the job.

In EMS that's true. In the hospital I think that the admitting docs whould prevent this situation by working with the families to make people on max life support no codes.
Dammit. Gotta go to a code in the ICU now. That's irony.

 

[pingouin]

My hospital is starting to let families come in and watch codes, but mainly in the unit. They've had 'good' experiences driving home the point of how sick their loved one is. I haven't tried this in the ER. Anyone have experience?

Prior to school, I was a SW at a Level 1 peds ED. During my time there, we also instituted a program of the parent(s) being allowed in the trauma rooms during any level- STAT, major, or minor. I generally brought them to a private consult room first to assess whether there were any obvious instabilities that would preclude them from going in, and to tell them the rules. Then I'd head to the trauma bay to confirm the docs were ready to have them in there (most of the time- yes). SW was required to chaperone the parent in and stay with them as long as they were in the room and the trauma call was still going on. They had to stay back by the door, and if they became overly distraught/disruptive in any manner that could compromise the medical team's efforts they were escorted back to the consultation room. The physicians made the call as to when the parent could be bedside- sometimes while they were still working on the kid, as it could help to calm them to have mom/dad holding their hand.

So I guess they've been doing that about 2 years now? Maybe 2.5. The ED SWs are currently in the process of collecting outcome data via patient/family and physician satisfaction surveys to determine whether this program is beneficial. Anecdotally, I'd say yes but we'll see what the data tells us. Obviously to do something like this requires good SW support (or someone who is specifically designated to work with the family)- not sure that all EDs have that resource available 24/7.

 

[Jeff698]

I have discussion about end of life care with every patient over 60, every hospital admission, and every nursing home patient.

Ah, so you're part of the "death panels"?

Granny killer.

Take care,
Jeff

 

[dmitrinyr]

I agree that PCPs have to do a better job of talking to their patients about the patient's and family's "end of life plan". I was a medical intern last year at a hospital where about 50-60% of the medical patients on the wards and ICU were nursing home patients and many of these pts were >80 y/o. Many of these patients were frequent flyers PEGed and trached with decubitus ulcers and multiple problems getting admitted to ICU with septic shock and of course the family that comes to see them once a month wants "everything done".

Still some families just don't understand and many times regardless of what we say to convince them that DNR is the best way for their loved ones and regardless of what the PCP says, they will still hang on to hope and want us to do everything.

In the ICU whenever we would have a patient that I knew would code soon and would not survive, I would press hard for DNR with each and every family member. When explaining the futility of the situation and the need of the DNR would not work, I would start getting graphic and describe what happens during a code. As they don't understand what actually goes on during a code, I would tell them that "if you family member's heart stops beating many people will come in an while giving her meds we will be pumping on her chest will all of our strength and many times breaking all her ribs during the process.... do you want that for her? wouldn't you rather her die in peace and not be tortured? The more graphic I get with the descriptions the more times they fold and sign DNR. Sometimes I would bring in one of the other residents who is 6 foot 7 inches tall and his hands are the size of most people's heads and say "Do you want this guy doing CPR on your mom?" That works really well.

Futile codes frustrated everyone involved and it takes us away from pts who were can help and save, plain and simple.

 

[Jeff698]

In the ICU whenever we would have a patient that I knew would code soon and would not survive, I would press hard for DNR with each and every family member. When explaining the futility of the situation and the need of the DNR would not work, I would start getting graphic and describe what happens during a code. As they don't understand what actually goes on during a code, I would tell them that "if you family member's heart stops beating many people will come in an while giving her meds we will be pumping on her chest will all of our strength and many times breaking all her ribs during the process.... do you want that for her? wouldn't you rather her die in peace and not be tortured? The more graphic I get with the descriptions the more times they fold and sign DNR. Sometimes I would bring in one of the other residents who is 6 foot 7 inches tall and his hands are the size of most people's heads and say "Do you want this guy doing CPR on your mom?" That works really well.

I think we have to be careful that we don't cross over the line into berating the family into doing what we think is the right thing. We in medicine profess a belief in patient autonomy and doing what the patient would want. It isn't our job to convince the family to do what we want.

I do feel your pain, though. I hate torturing grandma as much as the next doc and feel there is a special circle in hell for us for doing it.

Keep in mind that we don't have to continue CPR. If a code is futile, we don't need anyone's permission to cease resuscitation. If it ain't working, it ain't working and you can and should stop. You can then tell the family that 'everything was done'.

Take care,
Jeff

 

[EdibleEgg]

Ah, so you're part of the "death panels"?

Granny killer.

Take care,
Jeff

I prefer Steely-Eyed Dealer of Death or Geezer Slayer.

 

[Jeff698]

I prefer Steely-Eyed Dealer of Death or Geezer Slayer.

Oh, I like, I like.

Wouldn't that make a great tattoo?

You've seen those "we cheat death" logos? Perhaps we could design a more realistic EM one. Perhaps "I appease life-force-stealing-soul-sucking-dementors-from-hell?

Take care,
Jeff

 

[DogFaceMedic]

I have a slightly different take on futile codes.
Trying to educate 300 million people about what is futile or appropriate care is futile. We have all seen families that have not or will not make a decision about stopping care for weeks. There are always issues of guilt, money, etc.

Physicians also should not be the gatekeepers for gov't efforts to cut medicare costs. For us to force the decision invites many further complications from simple complaints to the hospital to complaints to Med Boards -- litigation is rare, although the threat is not.

Instead of us or the gov't trying to make the decision, put the financial onus back on the family. If they want to keep great great grandma in the ICU, they can pay for it themselves after we decidce it is futile. Also if the family wants to ignore medical directive for DNI/DNI, etc, they too can pay for it. Under these conditions, the coming to Jesus meeting by the family would happen a lot quicker.

 

[GeneralVeers]

I have a slightly different take on futile codes.
Trying to educate 300 million people about what is futile or appropriate care is futile. We have all seen families that have not or will not make a decision about stopping care for weeks. There are always issues of guilt, money, etc.

Physicians also should not be the gatekeepers for gov't efforts to cut medicare costs. For us to force the decision invites many further complications from simple complaints to the hospital to complaints to Med Boards -- litigation is rare, although the threat is not.

Instead of us or the gov't trying to make the decision, put the financial onus back on the family. If they want to keep great great grandma in the ICU, they can pay for it themselves after we decidce it is futile. Also if the family wants to ignore medical directive for DNI/DNI, etc, they too can pay for it. Under these conditions, the coming to Jesus meeting by the family would happen a lot quicker.

PAY?!? For medical care?? What country do you think you're living in?

 

[DogFaceMedic]

PAY?!? For medical care?? What country do you think you're living in?

You're right. Better to demand free healthcare, tax the crap out of businesses, and complain about jobs being exported overseas.

 

[GeneralVeers]

You're right. Better to demand free healthcare, tax the crap out of businesses, and complain about jobs being exported overseas.

Yep, that pretty much seems to be the plan right there.

 

[DogFaceMedic]

Yep, that pretty much seems to be the plan right there.

This discussion shows another dirty secret in current healthcare "reform" legislation: the gov't wants physicians to be the ones who deny care to the elderly. The gov't does not want to admit that is the goal. The implications of the legislation is to incentivizing (word?) or force physicians to deny care by cutting or denying other payments if we don't deny care -- just like the evil insurance companies.

 

[GeneralVeers]

This discussion shows another dirty secret in current healthcare "reform" legislation: the gov't wants physicians to be the ones who deny care to the elderly. The gov't does not want to admit that is the goal. The implications of the legislation is to incentivizing (word?) or force physicians to deny care by cutting or denying other payments if we don't deny care -- just like the evil insurance companies.

I'm fully in favor of denying care to the elderly who are poorly functioning and will have little benefit. I'm not in favor of denying care to elderly who are otherwise healthy and functional.

Still, if the government wants to "bend the cost curve" then cuts in care or rationing have to occur somewhere.

 

[Jeff698]

I'm fully in favor of denying care to the elderly who are poorly functioning and will have little benefit. I'm not in favor of denying care to elderly who are otherwise healthy and functional.

Yep. There's a HUGE difference between the 90 year old with horrible dementia, can't get out of bed, can't breath, can't pee, still thinks Nixon is president and the 90 year old who still does the NYT Sunday crossword in an hour and swims laps every day.

Take care,
Jeff

 

[BADMD]

Slightly shifting the topic, anyone read the paper in Annals about Termination of Resuscitation algorithms? Not earth shattering, but it basically validates the "Unwitnessed, Unable to defibrillate and no ROSC on scene" = no transport.

 

[beanbean]

I have had some success in getting previously difficult families to come around to making an ICU pt DNR/DNI when it was truly in the best interest of the patient. One statement I have used is when families have hope someone with a terminal will survive is: "Your loved one is dying. We need to talk about what kind of death they will have. A death in comfort surrounded by family or one of pain and suffering." It is wrong to badger or lie to a family to sway their choice, but I am brutally honest regarding what "do everything" really means.

 

[AmoryBlaine]

Refusing to perform CPR on a full code patient when you are the resident and not the responsible attending physician is a pretty cavalier move. None of us like it, but at our stage of the game, and our level of responsibility for what happens to this pt (far, far below that of the attending staff physician), this is not our decision to make. Just get to that chest and start pressing.

I think one of the big problems is not enough of the PCP's out there are having discussions w their pt's regarding code status, and then documenting these discussions. Every pt over the age of 80 who regularly sees primary care should have this discussion w their primary doc, and the doctor needs to document this in the chart. The ER visit for Grandpa Joe when he is brought in in PEA, brought back and then goes PEA again after his family arrives is not the time or place for this discussion to be had for the first time. One of the problems w good CPR is that sometimes it actually works...and how are we to expect a family who has just gotten to the ER and seen grandpa revived by the ER doing ACLS to then say, you know what, you guys are right, if he codes again you probably should just let him go. Not gonna happen. We had a case not too long ago where a 91yo dialysis pt w hemorrhagic brain mets on his CT scan coded on the CT table...we tube him and start coding him, he comes back, w/in 15min he's PEA again, he comes back (this scene keeps repeating itself, all told he had about 85min of ACLS performed on him), and the whole while our staff is explaining to the family how futile this process is and the only thing they are focused is on is how he keeps coming back so surely whatever you guys are doing is working.

Anyway, point being the ER is about the worst place in the world to be having the code status discussion and PCP-land is where this stuff should be happening.

I absolutely see your point. During this particular case it was in my mind more of a medical ethics thing than a chain-of-command issue.

It wasn't that I wanted to put myself in charge, merely that after a few snaps, cracks, and pops I felt that it was unethical for me to continue.

I'll get in there and do vigorous chest compressions with the best of them, and it isn't like every time I start pushing I decide whether or not I'll continue. Just in this personal case where the chance of survival was so clearly zero I just couldn't bring myself to continue...

 

[AmoryBlaine]

I have a slightly different take on futile codes.
Trying to educate 300 million people about what is futile or appropriate care is futile. We have all seen families that have not or will not make a decision about stopping care for weeks. There are always issues of guilt, money, etc.

Physicians also should not be the gatekeepers for gov't efforts to cut medicare costs. For us to force the decision invites many further complications from simple complaints to the hospital to complaints to Med Boards -- litigation is rare, although the threat is not.

Instead of us or the gov't trying to make the decision, put the financial onus back on the family. If they want to keep great great grandma in the ICU, they can pay for it themselves after we decidce it is futile. Also if the family wants to ignore medical directive for DNI/DNI, etc, they too can pay for it. Under these conditions, the coming to Jesus meeting by the family would happen a lot quicker.

The question is who will decide the futility? Even with clear guidelines and evidence practice patterns vary wildly (look at acute OM in kids).

In such an emotional decision you would essentially have to corrupt the doctor patient relationship by having the MD/DO establishing the point at which the family assumes cost for the critical care.

The only ethical way to do it would be some sort of objective score system, maybe APACHE or something like that. I think one way that could be used that would be unquestionably ethical would be to use it to assign code status i.e. if you meet a certain APACHE score you are not eligible for mechanical ventilation, renal replacement therapy, or ACLS. It sounds cold and bureaucratic but would save us from prolonging a lot of suffering.

 

[DogFaceMedic]

The question is who will decide the futility? Even with clear guidelines and evidence practice patterns vary wildly (look at acute OM in kids).

In such an emotional decision you would essentially have to corrupt the doctor patient relationship by having the MD/DO establishing the point at which the family assumes cost for the critical care.

The only ethical way to do it would be some sort of objective score system, maybe APACHE or something like that. I think one way that could be used that would be unquestionably ethical would be to use it to assign code status i.e. if you meet a certain APACHE score you are not eligible for mechanical ventilation, renal replacement therapy, or ACLS. It sounds cold and bureaucratic but would save us from prolonging a lot of suffering.

You make a good point about who decides and the implications. Most states have laws that require two docs, sometimes at least one neurologist, to decide if someone is incapacitated/brain dead/etc, or the state requires a court order to stop treatments. Another option is requiring an ethics committee to weigh in. There is a very good article by Edmund Pellegrino about what constitutes futility, and each case should be treated as unique.

I had the good fortune of working on some very good hospital ethics committees that could assist the IM or surgery staff to decide. Often the cmte was invoked to give the med staff cover from an indecisive family. It was a slow process, but often worked.

So, my thoughts are that if the state-specific laws are met and the family wants treatment that the docs decide is futile, they can take on the costs themselves.