"Mini Codes"

[The right Path]

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So-called modified/limited resuscitation measures.... discuss.

 

[docB]

Mini codes or slow codes don't exist. Just ask any hospital's risk manager.

 

[deleted89854]

I thought we were talking about coding little people.

 

[The right Path]

Mini codes or slow codes don't exist. Just ask any hospital's risk manager.

I can only speak for my hospital. Slow codes, while joked about, aren't done. However, there are patients with modified status such as- no intubation, no compressions, no shock, but pressors okay. Or some various combination.

In general mini-codes are the concession to the family that some effort will be made, while avoiding the "brutal interventions".

I guess no one has mentioned to these people that drugs injected into a vein don't circulate without someone mechanically squishing the heart between the rib cages. Not to mention that proper oxygen delivery is essential, and no that can't indefinitely be accomplished with an ambu bag or blowby O2.

 

[The right Path]

I thought we were talking about coding little people.

Lolz. That would be a new experience for me.

 

[docB]

I can only speak for my hospital. Slow codes, while joked about, aren't done. However, there are patients with modified status such as- no intubation, no compressions, no shock, but pressors okay. Or some various combination.

In general mini-codes are the concession to the family that some effort will be made, while avoiding the "brutal interventions".

I guess no one has mentioned to these people that drugs injected into a vein don't circulate without someone mechanically squishing the heart between the rib cages. Not to mention that proper oxygen delivery is essential, and no that can't indefinitely be accomplished with an ambu bag or blowby O2.

We all have processes to legitimately limit efforts. In my neighborhood we call it a Category II and they usually limit things like intubation, shocks, CPR, etc. The "slow codes" I've heard of in the past were more for patients were unsalvageable but still full code status.

I've actually always liked the "chemical code" option. It probably doesn't do any good but then neither does ACLS in general most of the time. The chemical code gives the family something to hang onto without punishing the patient with CPR, intubation, shocks, etc.

 

[The right Path]

We all have processes to legitimately limit efforts. In my neighborhood we call it a Category II and they usually limit things like intubation, shocks, CPR, etc. The "slow codes" I've heard of in the past were more for patients were unsalvageable but still full code status.

I've actually always liked the "chemical code" option. It probably doesn't do any good but then neither does ACLS in general most of the time. The chemical code gives the family something to hang onto without punishing the patient with CPR, intubation, shocks, etc.

Slow codes are actually not done because it is completely unethical. It's akin to telling someone you're giving them pain medication and shooting in saline.

I definitely don't equate a "slow code" to a limited code, but I don't think that limited codes are presented very honestly to families.

Full resuscitative measures are effective- if the underlying condition(s) are identified and reversible. Hypoxia due to mucous plug- successful. Hypoxia due to massive PE- forget about it.

But you're right in that there are soooo many cases of the resuscitated pt. that is just barely stabilized and maintained on respiratory and hemodynamic support until they code again, and again. The limited code precludes any of that nonsense because it ends with the first arrest. So I do see its value to some degree.

It just still sort of irks me that we are giving families a false reassurance. Another misconception that I think patients and families have is that they don't realize that just because someone has DNR status, does not mean that they will not be fully treated for their injury/illness.

It's nice to hear others' perspective on this.

 

[jdh71]

There really is no "in between". There should only be FULL code, or NO code. Anything else is a waste of medical time and resources. What good is intubation during a code if you can't do chest compressions. What good are epi and atropine during a code if you can't intubate a patient?

It's all ridiculous and needs to be a thing of the past, very few patients make it with a full court press anyway. Doing half measures is idiotic.

 

[The right Path]

There really is no "in between". There should only be FULL code, or NO code. Anything else is a waste of medical time and resources. What good is intubation during a code if you can't do chest compressions. What good are epi and atropine during a code if you can't intubate a patient?

It's all ridiculous and needs to be a thing of the past, very few patients make it with a full court press anyway. Doing half measures is idiotic.

Right, that's what I'm saying. How many physicians are up front with patients and families about that?

Limited codes are as effective in resuscitation as no code, so you could actually make the argument that it saves medical resources because it prevents that cycle of repeatedly coding a patient until the family finally has enough- which is a huge waste of medical resources not to mention a horrific way to die.

Then I also wonder if the limited code is not presented, would the net result be more families insisting on full code?

 

[docB]

No, I don't think so. Families have terrible understanding of end of life issues and what codes entail. Trying to get them to understand the futility is very difficult. Trying to get them to make a patient a no code often turns their anger/grief into anger at the hospital and staff because "They wouldn't do anything." It is often a very reasonable comprimise to present to the family that things look bad, we want to limit the painful and invasive things we do to their loved one but we will keep trying the non-painful things like medications. I am very comfortable with the "waste" in these situations which is a few hits of epi and atropine (very cheap) if by giving that option I can prevent a full code and all the futile trauma that entails.

 

[cpants]

IMO, what we need to do is get a firm list of indications for CPR. Cardiac arrest alone is not necessarily an indication, if a person is extremely unlikely to ever regain consciousness or leave the ICU.

Something like:
1. Cardiac arrest with a clearly reversible cause
2. Cardiac arrest in a patient with no known history (ie. "man down" situation)
3. Cardiac arrest PLUS
-NO end stage heart disease, pulmonary disease, renal or liver failure, or neoplasm
-NO irreversible, pervasive brain injury
-NO refractory hemorrhage
-AND Patient or family has been informed of the invasive nature of resuscitation and the likely outcome of intervention

If you code someone without proper indications...no reimbursement. And if you make it a habit, JCAHO investigations. This really is a drain financially and emotionally on patients, providers, and families, and it's time to put a stop to it. We don't do most invasive procedures without meeting strict indications, and the same should be true of ACLS.

 

[Stitch]

IMO, what we need to do is get a firm list of indications for CPR. Cardiac arrest alone is not necessarily an indication, if a person is extremely unlikely to ever regain consciousness or leave the ICU.

Something like:
1. Cardiac arrest with a clearly reversible cause
2. Cardiac arrest in a patient with no known history (ie. "man down" situation)
3. Cardiac arrest PLUS
-NO end stage heart disease, pulmonary disease, renal or liver failure, or neoplasm
-NO irreversible, pervasive brain injury
-NO refractory hemorrhage
-AND Patient or family has been informed of the invasive nature of resuscitation and the likely outcome of intervention

I think it would be highly impractical to make blanket policies about this sort of thing (even if the public would allow it! Talk about 'death panels'). Honestly the last thing we need is more JCAHO involvement in our lives. Moreover there are legal implications.

Coding isn't really the problem; by the time a patient is coding, you're too late. It's our inability to have end of life discussions, and the inability of the public to have realistic expectations about what medical care can and can't do. This kind of thing needs to happen at the PCP's office, and ideally even before becoming ill.

In some European countries the physicians are given much more leeway in saying 'that's it, there's no more we are going to do,' but I suspect that attitude is a bit paternalistic for the American palate.

 

[cpants]

I think it would be highly impractical to make blanket policies about this sort of thing (even if the public would allow it! Talk about 'death panels'). Honestly the last thing we need is more JCAHO involvement in our lives. Moreover there are legal implications.

Coding isn't really the problem; by the time a patient is coding, you're too late. It's our inability to have end of life discussions, and the inability of the public to have realistic expectations about what medical care can and can't do. This kind of thing needs to happen at the PCP's office, and ideally even before becoming ill.

In some European countries the physicians are given much more leeway in saying 'that's it, there's no more we are going to do,' but I suspect that attitude is a bit paternalistic for the American palate.

I agree with you that the act of coding isn't the problem, it's the lack of communication and planning that leads up to these situations. Making strict criteria for reimbursement for a code will put a strong pressure to have these conversations in a meaningful way prior to the moment of cardiac arrest or respiratory distress.

I feel that there is a tendency for doctors to approach this conversation in a cursory way, "Do you want us to do everything?" "Ok, your dad will be full code." In most cases, a slightly more paternalistic, or at least more informative, conversation can be more effective for everyone. "As you know your father is very sick and he's not going to get better. We need to plan for what will happen when he gets worse." "I don't feel comfortable performing CPR on your father, and here is why: unlikely to survive anyway, if he does it will almost certainly be in ICU on ventilator, this doesn't mean we are stopping all care, etc, etc." As with all of medicine, this is a decision that must respect patient autonomy and the individual patient's wishes. At the same time, patients look to physicians to provide the information, the risks and benefits of a procedure, and the likely prognosis and outcome. Most patients even want a firm recommendation of what to do. I don't think this intervention should be an exception.

Of course it's a conversation that should ideally happen in a PCP's office ages before a serious hospitalization. It should probably even be a reimbursable code - End of life planning or something. But if, as in many cases, that conversation hasn't happened, it needs to happen at the time of hospitalization.

 

[michaelrack]

One confusing aspect of "codes" for many patients (and some doctors) is that hospitals lump many things into the definition of a code. In some hospitals, a code will be called if a COPD'er is in severe respiratory distress. The decision on whether or not to intubate in such a case is different than the decision to intubate for cardiac arrest.

 

[docB]

I agree with you that the act of coding isn't the problem, it's the lack of communication and planning that leads up to these situations. Making strict criteria for reimbursement for a code will put a strong pressure to have these conversations in a meaningful way prior to the moment of cardiac arrest or respiratory distress.

I have a problem with this. I assume by "strict criteria for reimbursement" you mean cutting reimbursement for codes that really shouldn't have happened. This cut would be intended to motivate the primary doctor to communicate and head off these futile codes.

The problem is that in many hospitals those codes are not run by the primary doctor. In many community hospitals the ER doctor has to respond and run the code. Not reimbursing the ER doctor because of the primary doc's failure isn't just unfair, it won't cause the behavioral change you're looking for on the part of the primary doctors.

 

[cpants]

I have a problem with this. I assume by "strict criteria for reimbursement" you mean cutting reimbursement for codes that really shouldn't have happened. This cut would be intended to motivate the primary doctor to communicate and head off these futile codes.

The problem is that in many hospitals those codes are not run by the primary doctor. In many community hospitals the ER doctor has to respond and run the code. Not reimbursing the ER doctor because of the primary doc's failure isn't just unfair, it won't cause the behavioral change you're looking for on the part of the primary doctors.

No, I agree that cutting reimbursement for unnecessary codes wouldn't encourage the primary doc in most cases. However, it would at least encourage the team taking care of a pt in the hospital to have the discussion on admission, both b/c they want to get paid and the hospital wants to get paid. Like I said, we should encourage primary docs to have the talk ahead of time by reimbursing them to do so.

The bottom line is that you shouldn't get paid for unnecessary care, no matter what it is. From a financial and a moral standpoint I really just don't think we should be paying to code a guy with a 10% ejection fraction, for example, just to best case scenario keep his heart beating on a vent in the icu for a few more weeks to the tune of hundreds of thousands of dollars. That is futile care.

 

[The right Path]

IMO, what we need to do is get a firm list of indications for CPR. Cardiac arrest alone is not necessarily an indication, if a person is extremely unlikely to ever regain consciousness or leave the ICU.

Something like:
1. Cardiac arrest with a clearly reversible cause
2. Cardiac arrest in a patient with no known history (ie. "man down" situation)
3. Cardiac arrest PLUS
-NO end stage heart disease, pulmonary disease, renal or liver failure, or neoplasm
-NO irreversible, pervasive brain injury
-NO refractory hemorrhage
-AND Patient or family has been informed of the invasive nature of resuscitation and the likely outcome of intervention

If you code someone without proper indications...no reimbursement. And if you make it a habit, JCAHO investigations. This really is a drain financially and emotionally on patients, providers, and families, and it's time to put a stop to it. We don't do most invasive procedures without meeting strict indications, and the same should be true of ACLS.

Just to be clear, the only indications for CPR- are cardiopulmonary arrest.

However, it sounds like you envision a protocol/algorithm for deciding whether to proceed with intervention based on the likelihood of successful resuscitation and recovery of consciousness- which can be variable.

Obviously, the reason that this problem matters so much is because the line between appropriately aggressive treatment and futile inhumane treatment can be kind of blurry. Given any case scenario, you will find a wide range of opinions among health care professionals.

I don't want to sound like I'm tearing down your concept, because I see where you're coming from.

You brought up a lot of factors that may influence the outcome of resuscitation's success, and I was going to go over each one point by point. However, that is too lengthy of a project for me at this time, and would definitely border on rambling. If there is a specific factor that you have interest in, lemme know. Basically, it's not really feasible.

You had an interesting idea in rejecting reimbursement for resuscitations that could be considered inappropriate. However, the lawsuit implications are off the hook.

 

[The right Path]

I have a problem with this. I assume by "strict criteria for reimbursement" you mean cutting reimbursement for codes that really shouldn't have happened. This cut would be intended to motivate the primary doctor to communicate and head off these futile codes.

The problem is that in many hospitals those codes are not run by the primary doctor. In many community hospitals the ER doctor has to respond and run the code. Not reimbursing the ER doctor because of the primary doc's failure isn't just unfair, it won't cause the behavioral change you're looking for on the part of the primary doctors.

Extremely good point. Furthermore the ED physician or intensivist running the code often is not familiar with the patient's past and current medical history and has to get a summary of that on the fly while trying to stabilize the pt. His/her first priority isn't to evaluate the appropriateness of initiating the resuscitation.

 

[The right Path]

One confusing aspect of "codes" for many patients (and some doctors) is that hospitals lump many things into the definition of a code. In some hospitals, a code will be called if a COPD'er is in severe respiratory distress. The decision on whether or not to intubate in such a case is different than the decision to intubate for cardiac arrest.

That's actually the better scenario. The sooner that action is taken, the better. Rapid Response Teams actually are hugely beneficial in this regard because they are specifically designed to consult and recommend/implement treatment before the pt. crumps.

 

[cpants]

Just to be clear, the only indications for CPR- are cardiopulmonary arrest.

However, it sounds like you envision a protocol/algorithm for deciding whether to proceed with intervention based on the likelihood of successful resuscitation and recovery of consciousness- which can be variable.

Obviously, the reason that this problem matters so much is because the line between appropriately aggressive treatment and futile inhumane treatment can be kind of blurry. Given any case scenario, you will find a wide range of opinions among health care professionals.

I don't want to sound like I'm tearing down your concept, because I see where you're coming from.

You brought up a lot of factors that may influence the outcome of resuscitation's success, and I was going to go over each one point by point. However, that is too lengthy of a project for me at this time, and would definitely border on rambling. If there is a specific factor that you have interest in, lemme know. Basically, it's not really feasible.

You had an interesting idea in rejecting reimbursement for resuscitations that could be considered inappropriate. However, the lawsuit implications are off the hook.

Maybe it would have been more clear if I posed it as we need a list of contraindications for CPR. After performing a contraindicated procedure neither the physicians nor the hospital should expect to get paid.

I realize that at first cutting reimbursement might hurt some innocents who just showed up at a code. But soon there would be very strong pressure from colleagues and likely a change in hospital policy which would ensure that every admitted patient had appropriate resuscitation orders in place.

Unfortunately, it seems that the only way to change behavior in our system is through financial pressures. Look at what happened with nosocomial infections. Reimbursement rules changed for hospital acquired conditions, and all of the sudden this is the hot topic and any pt who has ever had a positive mrsa swab has full contact precautions.

 

[The right Path]

A physician cannot be held accountable for appropriate resuscitation status because that decision is entirely out of his/her hands and rightfully in the hands of the patient or DPOA.

The physician's influence can only go so far as to educate and advise. This endeavour and a huge one at that- is best accomplished by the good old fashioned office visit powwow including the patient and DPOA.

In this ideal situation, the involved parties are all present and hopefully of reasonably sound mental and physical functioning. There ought to be established familiarity and trust among the participants. (This is not going to be the situation in the ED in which a person(s) is under incredible physical/emotional stress and this subject is very cautiously being broached by this admitting doctor that they don't know from Adam.)

So, sounds reasonable right? So what's the problem?
Numero uno, people (overgeneralizing to make a point) will not talk about end of life issues. Period. They will talk ad nauseum about issues as irrelevent and asinine as Tiger Woods tomcattin' around, but they will not discuss death. That is American culture for you.

Secondly, how do you squeeze the "big talk" into your 15 min. appointment allotment? What billing code category does that fall under? Not much incentive for the primary care, either so it seems.

There did seem to be some progress in the idea of specifically reimbursing physicians for the sole purpose of having the "big talk". But then you have the self serving politicos screaming death panels, etc, etc.

 

[dpmd]

I would argue that the COPD'er in resp distress getting intubated isn't that much better than the random old person getting CPR. Especially someone who has already had multiple admissions in the prior months and a couple of ICU stays thrown in there. They are a bigger money drain than the grandma that gets CPR, gets brought back for a little while then finally fails to come back (or the family finally comes on board, or the doctor running the code shuts it down after only a few rounds instead of going ball's out for 30+ min)

 

[The right Path]

I would argue that the COPD'er in resp distress getting intubated isn't that much better than the random old person getting CPR. Especially someone who has already had multiple admissions in the prior months and a couple of ICU stays thrown in there. They are a bigger money drain than the grandma that gets CPR, gets brought back for a little while then finally fails to come back (or the family finally comes on board, or the doctor running the code shuts it down after only a few rounds instead of going ball's out for 30+ min)

Agreed.

The COPDer is a special animal. They'll code sure as sh.. if they're left to their own devices, and trying to extubate? Hah. They need a lot of aggressive pulmonary toilet in order to maintain, plus some quality time with the bipap. They are time/money/labor intensive whether they actually arrest or not.

 

[cpants]

I would argue that the COPD'er in resp distress getting intubated isn't that much better than the random old person getting CPR. Especially someone who has already had multiple admissions in the prior months and a couple of ICU stays thrown in there. They are a bigger money drain than the grandma that gets CPR, gets brought back for a little while then finally fails to come back (or the family finally comes on board, or the doctor running the code shuts it down after only a few rounds instead of going ball's out for 30+ min)

Except the major difference is that intubating a COPD-er can have a good outcome. Giving that patient ventilator support can allow him to extend his life by weeks or months, while still maintaining a high level of consciousness, interacting with family members, and generally having some quality of life. This is in contrast to a situation where that same COPD pt goes into cardiac arrest and is found unresponsive. In that case, CPR is likely futile, as the person is unlikely to ever regain consciousness.

 

[The right Path]

Except the major difference is that intubating a COPD-er can have a good outcome. Giving that patient ventilator support can allow him to extend his life by weeks or months, while still maintaining a high level of consciousness, interacting with family members, and generally having some quality of life. This is in contrast to a situation where that same COPD pt goes into cardiac arrest and is found unresponsive. In that case, CPR is likely futile, as the person is unlikely to ever regain consciousness.

Putting the various other factors such as severity of COPD aside,
it is very difficult to wean to extubate someone with COPD, often times needing the intermediary step of a trach.

"Giving that paitent ventilator support can extend his life by weeks or months, while still maintaining a high level of consciousness, interacting with family members, and generally having some quality of life."

Actually, in reality, those last few weeks or months will be spent in the hospital, wrists strapped down with tubes in every orifice, and struggling to communicate around an ETT or with a trach. In this case a high level of consciousness is not a good thing. Quality of life?

These are things for the healthcare team and the family to consider when deciding how aggressively to intervene including code status. Furthermore, there are so many variables, it can only be taken on a case-by-case basis.

Anyone who arrests (regardless of mechanism and co-morbidities) is at risk for anoxic encephalopathy. Immediate circulation of oxygenated blood is the only thing that can prevent that. Hypothermia treatment may be of some benefit as well.

 

[fab4fan]

Except the major difference is that intubating a COPD-er can have a good outcome. Giving that patient ventilator support can allow him to extend his life by weeks or months, while still maintaining a high level of consciousness, interacting with family members, and generally having some quality of life. This is in contrast to a situation where that same COPD pt goes into cardiac arrest and is found unresponsive. In that case, CPR is likely futile, as the person is unlikely to ever regain consciousness.

You've got to be kidding me. You think being stuck on a vent for weeks to months, only to ultimately die is quality of life? People like you are why people like me drew up advance directives long, long ago. I'm sure your intentions are good, but...

The last thing I would want to see is physicians being penalized for good faith efforts during resuscitation. Isn't it enough that we have an ever-growing list of "Never-Events" that CMS refuses to reimburse?

 

[Hernandez]

That's actually the better scenario. The sooner that action is taken, the better. Rapid Response Teams actually are hugely beneficial in this regard because they are specifically designed to consult and recommend/implement treatment before the pt. crumps.

Have there been any studies which show that RRs are benficial in anyway other than decreasing "codes". My personal experience in my hospital is that codes were called all the time for non-cardiopulmonary failure and we simply now just call them RRs. I'd love to see if RRs actually decrease mortality with their implementation.

 

[Stitch]

Have there been any studies which show that RRs are benficial in anyway other than decreasing "codes". My personal experience in my hospital is that codes were called all the time for non-cardiopulmonary failure and we simply now just call them RRs. I'd love to see if RRs actually decrease mortality with their implementation.

I don't have the data on hand at the moment, but Hopkins did a study on rapid response teams from a PICU perspective. The data I saw indicated that it cut their respiratory arrests in half, but had no effect on their cardiac arrests. My impression at the time (a year or so ago) was that it basically helped those kids who sat on the floor in respiratory distress and got ignored. Say your sick RSVs or worsening asthmatics. Those kids either avoided going to the unit or got earlier intervention that avoided a code situation. However kids with bad hearts died anyway. I suspect that these results are indicative of the relative rarity of heart problems in kids, but does show that we need to keep closer tabs on distressed kids on the floor, especially since most pediatric arrests are a result of some sort of airway/breathing problem.

I've not seen any adult literature, but then I've never looked for it.

 

[The right Path]

I'm not sure I want to launch a full scale literature review, but did a quickie search of CINAHL data bases. There are several studies published. I did print out some full texts and some citations that I might later on look at the full text. At this point, I've only given them a cursory once over.

So far it seems that the outcome variables that are most frequently studied are code rate and mortality rate. With most studies reporting a decrease after RRT implementation. A big exception is a study published in JAMA in 2008.

I think it would be hard to eliminate confounding factors because during the "before and after RRT implementation" time period, there are so many other changes that occur in policy and practice that can very well affect the code/mortality rates. It would be a lot easier if you could randomly assign access to the RRT, but well of course that's unethical.

It takes a lot of scrutiny to tease out the statistical significance, reliabilty, validity, yada yada of those other variables. And that's the cool/frustrating thing about research (for me anyway),- the harder you work to look for answers, and the closer you think you get, the more questions, and what-ifs, whatabouts you generate.

I'm not going to dedicate a lot of time to this, but I'll look into it when I can. If I come across something interesting, I'll post it in a new thread dedicated to RRT.

Also as an FYI, the RRT is basically a mandate of the Joint Commission to satisfy the National Patient Safety Goal #16. So when it comes down to it, it really doesn't matter whether research shows improved outcomes. The Joint Commission says ya gotta do it so that's it.

 

[The right Path]

Oops

 

[cpants]

You've got to be kidding me. You think being stuck on a vent for weeks to months, only to ultimately die is quality of life? People like you are why people like me drew up advance directives long, long ago. I'm sure your intentions are good, but...

The last thing I would want to see is physicians being penalized for good faith efforts during resuscitation. Isn't it enough that we have an ever-growing list of "Never-Events" that CMS refuses to reimburse?

Bravo to you for taking your end-of-life care into your own hands. Better for all of us to make these decisions well in advance.

Maybe you just haven't seen it done well, but people can be made comfortable on ventilatory support. Quality of life means different things to different people, and there is always a balance between quality and quantity of life. However, for a lot of people, hanging on for a few weeks can mean seeing a newborn grandchild or just getting a chance to say goodbye to their relatives. Some COPD-ers may even be weaned from the ventilator after steroid treatment. In other words, ventilating may buy them more ventilator-free time with loved ones.

 

[The right Path]

Bravo to you for taking your end-of-life care into your own hands. Better for all of us to make these decisions well in advance.

Maybe you just haven't seen it done well, but people can be made comfortable on ventilatory support. Quality of life means different things to different people, and there is always a balance between quality and quantity of life. However, for a lot of people, hanging on for a few weeks can mean seeing a newborn grandchild or just getting a chance to say goodbye to their relatives. Some COPD-ers may even be weaned from the ventilator after steroid treatment. In other words, ventilating may buy them more ventilator-free time with loved ones.

QUOTE=cpants;9071259]


I can't speak for fab4fan, however I will speak to this issue with a significant degree of authority, and I think s/he would back me up. I have 5+ years (and I believe fab4fan actually has quite a bit more) experience in direct care of patients with varying degrees of COPD and other co-morbidities. I have earned certification that validates my expertise in managing patients that are critically ill including those that need mechanical ventilation. A huge aspect of caring for ventilated patients is providing comfort measures. I bring this up to refute your statement "Maybe you just haven't seen it done well, but people can be made comfortable on ventilatory support." which is frankly extremely presumptuous, especially coming from the perspective of a medical student. And that is not a put down- you've just begun your education in medicine and your clinical experience is very limited.

Therefore, coming from a position in which the highest standards of practice are utilized in managing ventilated patients- all the pharmacologic and nonpharmacologic comfort measures do not necessarily mitigate the discomfort of an endotracheal tube, suctioning, etc. This is on top of the discomfort of trying to adequately ventilate and oxygenate through a tube with a lumen no wider than my thumb. Not as easy as you'd assume with a healthy set of lungs. Try it sometime- if you you can get your hands on an unused ETT. It would actually be a more accurate analogy to breathe through a drinking straw in and out for at least 15 min.- aren't you glad that breathing isn't like that 24/7 for you?

We can discuss the anatomy, and pathophysiology and treatments, ventilator strategies all day long, my friend. But the point that I'm trying to make is quality of life takes a sharp nose dive at the end stages of COPD. And you are absolutely correct that quality of life means different things to different people. You have suggested that a person may wish to endure CPR and intubation to give that person a chance to see a newborn grandchild. I can't speak to other ICU's policies, but we don't allow children under 12, and particularly immunologically vulnerable newborn babies into the unit except for some extremely rare cases. And as far as coding someone so that relatives will have an opportunity to "say goodbye" is quite illogical. The fact that "we" the healthcare industry prolong suffering through futile care due to the family's inability to let go, is a travesty. This is even done against a patient's advance directive wishes, as the DPOA can reverse DNR status at any time. And it happens a lot.

And again we can discuss various family dynamics and circumstances ad nauseum, but it doesn't change the fact that after resuscitating a patient with severe COPD, even if we can keep him/her stable enough to make it a few more weeks and months, their ability to spend quality time with loved ones (even just to look at baby picture or say goodbye) is dubious. It is highly unlikely (particularly with this subset of patients) that even with successful resuscitation, they will recover to their baseline level of health. In other words, after resuscitation, they are in far worse condition than they were pre-arrest and while they can improve from being pulseless and apneic, they will never be as well as they were before they arrested. Yes, there is always that one exceptional anecdotal case that surprises everyone- however I personally have yet to see it.

It has been interesting to read your perspective on intubating COPD'ers when their life expectancy is only a few more weeks. Weren't you pretty adamant that resuscitating patients that are expected to have poor outcomes should be stopped? Even to the point that perhaps hospitals ought not to be reimbursed for resuscitative interventions?

Welcome to medicine. Issues are not black and white and people aren't necessarily consistent within themselves. Your knowledge and opinions will change as you grow and gain experience. I think it is great that you enter into controversial discussions. Keep up the good work.

 

[dpmd]

I have seen a couple of people here and there awake, calm and interactive on a vent, but this has always been in someone who we have plans of extubating soon (or traching if the airway is the problem). I think that the reassurances that it won't be much longer went a long way to keep them calm. All my other patients have been pretty much out of it (either requiring a bunch of sedation to control behavior, or just not awake even without sedation). I suppose if the thought is that they will eventually become vent independent you can argue for intubation, but after a the third or fourth time that happens in a year you gotta wonder if it is worth it.

 

[The right Path]

I have seen a couple of people here and there awake, calm and interactive on a vent, but this has always been in someone who we have plans of extubating soon (or traching if the airway is the problem). I think that the reassurances that it won't be much longer went a long way to keep them calm. All my other patients have been pretty much out of it (either requiring a bunch of sedation to control behavior, or just not awake even without sedation). I suppose if the thought is that they will eventually become vent independent you can argue for intubation, but after a the third or fourth time that happens in a year you gotta wonder if it is worth it.

Of course, of course- they're not the ones I meant.

I was referring to the patient requiring high FiO2, high PEEP, struggling to keep the peak pressures under 30 so you don't blow a pneumo just to keep an adequate pO2 to keep their cardiac cells and neurons alive, never mind a conscious sensorium. Making deals with Jesus every time you suction their airway, or reposition their body. Strapping down their feeble little wrists so they don't dislodge their airway in their confused hypoxic feeling like a fish out of water anxiety. Just so they can hang in there a few more weeks, days, your shift.... because they are full code, and god knows it's hard enough to be complicit in what's already going on. Throwing CPR on top of that scenario, and that's when you're ready to walk out the door and not look back.

That's when I'm partially satisfied with a "mini code" scenario.

 

[cpants]

I can't speak for fab4fan, however I will speak to this issue with a significant degree of authority, and I think s/he would back me up. I have 5+ years (and I believe fab4fan actually has quite a bit more) experience in direct care of patients with varying degrees of COPD and other co-morbidities. I have earned certification that validates my expertise in managing patients that are critically ill including those that need mechanical ventilation. A huge aspect of caring for ventilated patients is providing comfort measures. I bring this up to refute your statement "Maybe you just haven't seen it done well, but people can be made comfortable on ventilatory support." which is frankly extremely presumptuous, especially coming from the perspective of a medical student. And that is not a put down- you've just begun your education in medicine and your clinical experience is very limited.

Therefore, coming from a position in which the highest standards of practice are utilized in managing ventilated patients- all the pharmacologic and nonpharmacologic comfort measures do not necessarily mitigate the discomfort of an endotracheal tube, suctioning, etc. This is on top of the discomfort of trying to adequately ventilate and oxygenate through a tube with a lumen no wider than my thumb. Not as easy as you'd assume with a healthy set of lungs. Try it sometime- if you you can get your hands on an unused ETT. It would actually be a more accurate analogy to breathe through a drinking straw in and out for at least 15 min.- aren't you glad that breathing isn't like that 24/7 for you?

We can discuss the anatomy, and pathophysiology and treatments, ventilator strategies all day long, my friend. But the point that I'm trying to make is quality of life takes a sharp nose dive at the end stages of COPD. And you are absolutely correct that quality of life means different things to different people. You have suggested that a person may wish to endure CPR and intubation to give that person a chance to see a newborn grandchild. I can't speak to other ICU's policies, but we don't allow children under 12, and particularly immunologically vulnerable newborn babies into the unit except for some extremely rare cases. And as far as coding someone so that relatives will have an opportunity to "say goodbye" is quite illogical. The fact that "we" the healthcare industry prolong suffering through futile care due to the family's inability to let go, is a travesty. This is even done against a patient's advance directive wishes, as the DPOA can reverse DNR status at any time. And it happens a lot.

And again we can discuss various family dynamics and circumstances ad nauseum, but it doesn't change the fact that after resuscitating a patient with severe COPD, even if we can keep him/her stable enough to make it a few more weeks and months, their ability to spend quality time with loved ones (even just to look at baby picture or say goodbye) is dubious. It is highly unlikely (particularly with this subset of patients) that even with successful resuscitation, they will recover to their baseline level of health. In other words, after resuscitation, they are in far worse condition than they were pre-arrest and while they can improve from being pulseless and apneic, they will never be as well as they were before they arrested. Yes, there is always that one exceptional anecdotal case that surprises everyone- however I personally have yet to see it.

It has been interesting to read your perspective on intubating COPD'ers when their life expectancy is only a few more weeks. Weren't you pretty adamant that resuscitating patients that are expected to have poor outcomes should be stopped? Even to the point that perhaps hospitals ought not to be reimbursed for resuscitative interventions?

Welcome to medicine. Issues are not black and white and people aren't necessarily consistent within themselves. Your knowledge and opinions will change as you grow and gain experience. I think it is great that you enter into controversial discussions. Keep up the good work.

Though you chose to treat them as the same intervention in your post, CPR and intubation are different. While full CPR (chest compressions, medications, and/or defibrillation) is usually not indicated in an end stage patient, intubation, Foley catherization, antibiotics, IVF, nutritional support, and any number of other life-prolonging interventions may be indicated. It's lumping other interventions in with DNR orders which makes DNR patients receive substandard care when compared to "full code" patients.

As to COPD, yes it is a chronic and progressive disease, with poor prognosis at the end stages. It is also a disease of exacerbative episodes. Many patients will require intubation during their course. Many patients, even stage IV patients, can then be weaned from that ventilator following appropriate steroids, bronchodilators, and pulmonary toilet. Am I saying their pulmonary function returns to baseline? No. I am saying that the intervention can frequently prolong life, including ventilator-free life. Did I say a ventilator is comfortable and pain free? No. I said that comfort can be maximized, and in many cases patients can be made relatively comfortable and anxiety free and can be eased in and out of sedation to interact with family members. I've even seen a patient on vent watching a movie with his wife and writing notes to her on a pad. I wasn't questioning the "significant degree of authority" which your 5 years of nursing experience gives you, I was simply stating that maybe you haven't seen it done well. It's not a knock on you or your experience. Not many docs do it well, and I've certainly seen comfort management done poorly many (if not most) times.

Finally, why don't you tone down the condescension a bit? You criticize me for being "presumptuous" of others' experience, and then you pompously (and incorrectly) define my experience as limited to 3 years of medical school and inferior to your own. I have all the respect in the world for nurses, but being on the medical team is pretty different than being on the nursing team. And I imagine you know this, or you wouldn't be looking to change careers. By the way, not allowing children under 12 in to see a dying loved one isn't exactly at the cutting edge of palliative medicine. Forward thinking hospitals are getting a lot more flexible with visitation regulations, especially for dying patients.

 

[The right Path]

Though you chose to treat them as the same intervention in your post, CPR and intubation are different.

I just want to reassure you that I do know that CPR and intubation are not interchangeable. In a situation in which a patient is in such a degree of respiratory distress, that they need to be intubated, but don't get intubated, the end result will be a fatal dysrhythmia, usually PEA. If the root cause of the respiratory distress is treatable, the chances for a good outcome and extubation are good. If the root cause is end stage COPD complicated by pneumonia, or resulting in spontaneous pneumos for instance, the outcome is not so good-even though the patient didn't technically arrest necessitating the intubation with the CPR/ACLS cherry on top. It is in those circumstances, that I don't believe there is much quality of life (though admittedly highly subjective) to be had while being maintained on the ventilator.

While full CPR (chest compressions, medications, and/or defibrillation) is usually not indicated in an end stage patient,
intubation, Foley catheterization, antibiotics, IVF, nutritional support, and any number of other life-prolonging interventions may be indicated. It's lumping other interventions in with DNR orders which makes patients receive substandard care when compared to "full code" patients.

Whoa, whoa, whoa, whoa when didn DNR ever equal "substandard care?" Where have antiobiotics or IVF, or even a freaking Foley ever been excluded due to DNR status? My grandmother is 86 years old and "DNR" and yet has had major thoracic reconstructive surgery due to a tumor that destroyed part of 3 ribs and part of her sternum and has been treated for UTI sepsis. Never, ever was she denied appropriate care. Now if her lungs were so compromised due to cancer that she needed to be intubated, would I recommend that for her? Hell no. If her UTI had not been treated early and appropriately and she progressed to MODs/severe sepsis requiring pressors and/or intubation, would I recommend that for her? Hell no. And that's even before getting to the point that she needs CPR.

As to COPD, yes it is a chronic and progressive disease, with poor prognosis at the end stages. It is also a disease of exacerbative episodes. Many patients will require intubation during their course.

Thank you, but I am quite familiar with the nature and patterns of COPD.

Many patients, even stage IV patients, can then be weaned from that ventilator following appropriate steroids, bronchodilators, and pulmonary toilet.

I'm not saying that this statement is wrong, but I don't accept this claim at face value, having not compared a pt.'s FVC/FEV1 measurements to their success in weaning/extubating. If I have the opportunity I will look into it at work on an anecdotal level. If I have the time, I can search the databases to see if those specific variables are studied and published. Of course other factors are involved such as presence of cardiac disease (particularly since cor pulmonale goes hand in hand with COPD), and amount and character of pulmonary secretions.

Am I saying their pulmonary function returns to baseline? No. I am saying that the intervention can frequently prolong life, including ventilator-free life. Did I say a ventilator is comfortable and pain free? No. I said that comfort can be maximized, and in many cases patients can be made relatively comfortable and anxiety free and can be eased in and out of sedation to interact with family members. I've even seen a patient on vent watching a movie with his wife and writing notes to her on a pad.

What you had actually said, that I took issue with is, "Giving that patient ventilator support can allow him to extend his life by weeks or months." "Maybe you just haven't seen it done well, but people can be made comfortable on ventilatory support."

I'm glad you requalified that as "relatively comfortable and anxiety free." And just to be clear, I've never stated that a person that is intubated is going to be miserable and unable to interact with family. However, a person that is in such a condition that intubating him/her only buys a few weeks or months, is not going to present as the man hanging out with his wife and watching movies. It's a totally different picture. That's when you're faced with the not so inspiring challenge of balancing physiologic stability with comfort. Which brings me to.....

I wasn't questioning the "significant degree of authority" which your 5 years of nursing experience gives you, I was simply stating that maybe you haven't seen it done well. It's not a knock on you or your experience. Not many docs do it well, and I've certainly seen comfort management done poorly many (if not most) times.

I guess you didn't intend to, but to insinuate (and yes you did) that I have not provided nor even seen for that matter, patients' comfort adequately managed is a huge insult. Pain/anxiety management is the responsibility of all healthcare disciplines on a collaborative level. Fortunately there is more emphasis on addressing these issues than there were years and years ago. And still, obviously, there is vast room for improvement. I don't know what background or experience that you come from, but my instinctive reaction to statements such as this- "was simply stating that maybe you haven't seen it done well. It's not a knock on you or your experience. Not many docs do it well,...." honestly, is where does this med student get off criticizing experienced health care professionals.
True, there are those who are notorious for prioritizing comfort last. However, that's not the majority. From a pharmacologic standpoint, narcotics and anxiolytics can compromise a patient's physiologic status, so there are limits to how much and how often they can be given. And the more unstable, they are, the more careful you have to be. It really sucks to be in the position to have to choose physiologic stability over comfort.

Case in point: Within the past 3 weeks, I've taken care of 2 patients that required nasotracheal suction. If you're not familiar with the procedure, it is sticking a tube about the width of a pen down a nostril all the way to the trachea in order to suction out the thick copious pulmonary secretions that they are too weak to cough up. And do you think they are really cool with you doing that? No, they would try to push you away if they weren't restrained. Is it a one time deal? No, the patient is probably going to need it again in a couple hours. Does morphine and/or Ativan help make the procedure more tolerable? Maybe a little, but if you gave too much you would be knocking down with one hand what you tried to build with the other. Well, if the patient didn't want me to do it, why did I? Well, both of these patients are full code, and if I hadn't cleared their airway of secretions, they would have continued to desaturate until they coded, at which time they would have continuous discomfort with the ETT rather than the in and out suction.

You can have someone so plowed under with narcotics and sedation that they can't even open their eyes when you shout in their ear and shake them, yet they will still grimace when you suction their ETT, or turn them, or perform an ABG, etc, etc. Pain is a beast of a problem, that's the bottom line.

So I guess my point is that it is easy to sit on the sidelines and say that patients comfort needs aren't adequately met. And in many cases that is true. Unfortunately, the answers aren't that simple, but it shouldn't stop anyone from trying.

Finally, why don't you tone down the condescension a bit? You criticize me for being "presumptuous" of others' experience, and then you pompously (and incorrectly) define my experience as limited to 3 years of medical school and inferior to your own. I have all the respect in the world for nurses, but being on the medical team is pretty different than being on the nursing team. And I imagine you know this, or you wouldn't be looking to change careers.

You're right, I really don't know what the extend of your healthcare knowledge or experience is. And based on the content of your posting, I did make an assumption. Feel free to enlighten me.

I find it interesting that you would say "being on the medical team is pretty different than being on the nursing team." Of course I know what nursing scope of practice is and medical scope of practice is. And as you can see, I hope, end of life and comfort vs. intervention issues is collaborative issue.


And by the way,...."And I imagine you know this, or you wouldn't be looking to change careers."

I'm not, as you state, changing careers because I'm unsatisfied with my scope of practice. I am interested in forensic pathology.

By the way, not allowing children under 12 in to see a dying loved one isn't exactly at the cutting edge of palliative medicine. Forward thinking hospitals are getting a lot more flexible with visitation regulations, especially for dying patients.

I work in an ICU and NSICU. The focus is not palliative medicine. Of course we make referrals the palliative team when appropriate. When we have a patient that becomes "comfort care" we do what we can to transfer them to a private med/surg room so that the family isn't as inhibited by our "rules". I didn't state my position on our visitor policy. I also realize that many ICUs are trending toward open door policies. For reasons I won't go into, that's not really appropriate for units. But that's not to say that we don't make exceptions to the "rules" when reasonable.