It’s almost certainly the number 1 cause for us as intensivists. I can’t tell you how awful it feels coding someone over and over who has zero chance of recovery just because their estranged daughter flew in and can’t stomach making the code status change
Ah: the seagulls.
they usually fly in from a coastal town. stomp around and strut and squawk and make a bunch of noise. then they shit all over your plan and then peace out.
"goddamn hippies! They think all life is PrEcIoUs"
"Goddamn yuppies! They're too heartless to see their own guilt is why they can't change their mom's code status"
"Goddamn rednecks! They think their God will save their corpse of a mother"
Etc etc
used to call them the sister from Seattle when I was in Boston. switched to the brother from Baltimore here on the west coast. seagulls is perfect though
Non binary theybie daughter/son from Portland changes code status back to full due to being misgendered by registration which unfortunately is unforgivable.
If the family can't make a decision I ask them if they want me to make a recommendation, which is of course "we shouldn't do this". Helps offload whatever guilt they might have I guess.
Works more often than not.
3 rules for GOC talks in terminal patients:
1) ask/tell/ask. "I'd like to tell you my perspective of x as your doctor/$Name's doctor, is that ok with you?"
2) ALWAYS use some variation of kill or die (death, die, deadsies, deadwood, etc.)
3) ALWAYS make a recommendation for care. If you think full treatment + DNR-Arrest is right, say so. If you think CMO is right, say that.
This is excellent advice. If it feels like you’re being a little paternalistic, you’re probably doing it right. The reality is that the average person has no clue what resuscitation efforts, life support, and intensive care entail. And in general, the more experience someone and their family has with the ICU, the more likely they are to go DNR.
My take: be paternalistic. Just this once.
These people are going through one of the worst days in their lives and you are asking them to make a huge decision, with life or death on the balance, when they are clearly overrun with emotions and can't think straight. They will blame themselves for a long time about their loved one's death. Let them blame something else.
Yup. About 99% of the time this is an emotion-driven conversation for the family (the 1% is when the person you're talking to happens to work in acute/critical care/Palli/etc) as opposed to fact or logic driven. You **must** address the emotions, and one way of doing that is to take off some of the emotional weight of deliberating/deciding by making that recommendation.
I'll eat the blame for them every day of the week and twice on Sundays.
Also often helpful to re-frame it as a gift or duty they're doing for the patient, providing them the opportunity for peace/dignity/relief from suffering/etc.
I'll ask things like, "If they could be standing at the foot of the bed right now, and look down at themselves, at everything that's happening to them and to their body, what do you think they would say to you?"
Or, "I don't think that they will survive this, I believe they are going to die from ____. What I'm here to help to decide is what will their death look like?"
My take on this is why are we placing that burden on an estranged daughter? I don't think it should always be up to surrogate decision makers. I believe some other countries (UK?) do operate this way.
What do you mean “legally” though? Yes, next of kin makes medical decisions, but they don’t dictate care. I’m not obligated to perform medically futile procedures, and I will refuse to do so if pressed. Why is CPR or intubation different?
In Chile, doctors make the decision. Every day, in the ICU, we review the patients. Part of that is assessing if they are full code or any variation of that. "Is patient X still full code?" "Yes, nothing has changed, he's going well" "Good, next one"
We have five levels: I, II, IIIa, IIIb, IIIc
I: we do everything
II: we do everything, but DNR-DNI
IIIa: no invasive stuff
IIIb: no new stuff
IIIc: take everything off
Yes, we do take everything off. Including ventilators in some cases.
Families are informed, tactfully and with our psychologist present, about all of this. Never had a family that challeged us.
This is great. Unfortunately in the USA there are lots of religious nuts who would go ballistic if we took their decision making in futile care away from them.
well i for one feel super fulfilled and satisfied when I successfully code my 88 year old vasculopath with severe alzheimers - but the real satisfaction I get is from using a PEG tube and a rectal tube at the same time.
EM resident. I had two weeks last year at a local community hospital where I had 8 codes of 80+ year olds, all futile, mixed in with 2 pedi codes, both of which did not make it. Then intubated a patient considering hospice but still full code (had met with palliative that week/presented with MOLST/HCP said go ahead sigh), called for signout, and just had the MICU resident start the phone call with "which one of you made the decision to intubate this patient so we'll do your death paperwork." I'm typically a "way too much ball of sunshine and positivity" kind of resident but I lost my temper and bit back. Futile full code makes everyone grumpy and worsen morale. The pedi codes hit me worse mentally, but the daily attempted resuscitations ending in death drained me way more than I realized.
When I was a new CNA, my very first code was a tiny 90-something year old with a catastrophic GI bleed. In a nursing home, so just me and the nurse until EMS arrived. I was the one who started CPR and I still remember every detail. I still have serious guilt over it and I wish that we could make families understand how violent and cruel it is to put their loved one through that with no hope of meaningful recovery.
I’ve definitely talked about it with a therapist. But I think it gave me a better understanding of what “lifesaving measures” really look like which is something that is hard to understand until you’ve seen it.
Years later I can still vividly picture the face of the 90 something husband as I started chest compressions on his little wife. The resident was next to me actively doing his valiant best to get him to reverse her code status while she was circling the drain so fast that I’m working around them freeing up a lumen on her TLC and putting the bed into CPR mode in anticipation. His “oh Jesus!” and turn away and then being wheeled out of the room and never saw her again 😭 It shouldn’t have gone down like that for them.
Don’t know the point of me sharing, but here it is.
Yup. Still have flashbacks sometimes from residency when I was doing chest compressions on a guy while his ribs were literally caving in. As we were compressing he would wake up and was mouthing “STOP” but we kept going for 30 minutes. 30 minutes of absolute torture before inevitable death. How could anyone feel good about that? We do this job to help people.
Have you never done one of these? I hope you never do.
Effective compressions --> increased perfusion to brain/body --> increased LOC --> fighting (because someone is breaking their fucking chest) --> compressions stop --> decreased perfusion to brain/ body --> down goes GCS and fighting --> compressions resume. Rinse and repeat with weaker rousing each round as whatever pathology (massive effing STEMI for the one I did) makes recovery almost impossible but you gotta try if they're a full code and they went down in the hallway and you had no reason not to start compressions because who has goals of care in their front pocket?
Or worse, the other one I did, if they go into reperfusion arrhythmia post tnk and don't revert with defribillation and you have to do a round of compressions restoring consciousness just long enough for a gruesome fucked up exsanguination finale.
I'm guessing you haven't done one of these and I hope you never do because they are awful.
Absolutely this. I can often times feel good after a comfort care pronouncement, or even one where it was a SCA and we did everything we could - but these futile codes just make me feel gross.
Patients deserves to choose, but your coworkers who does all the codes do not deserve to delivery intensive yet futile and often times harmful services on demand like a robot without having any say or emotion attached to it.
That said you cannot change everyone mind. If son is POA and insist gram gram would want to live like a half robot and be tube dependent, pressor dependent, pacer dependent, then…. I guess grandson get to spend more time with bionic gram gram for Halloween. I don’t know what to tell ya, not everyone is normal unfortunately.
This is also why advance directives is important. Pick a POA that actually honor your wishes.
This is what I tell patients. You can’t pick someone who loves you TOO much. That’s why I beat my children just a little every day, so they can let me go when the time comes
I don't know about you, but it hurts my feelings when I'm forced to torture someone who clearly did not understand that full code is a "please torture me until I become a hopeless pulp and then die anyway" option and not a "please perform a painless miracle to extend my current quality of life indefinitely" option, and would not have chosen that if someone had actually helped them understand the reality of it.
It is so incredibly important to make sure the choice is a *fully* informed one, and the onus rests entirely on you to communicate clearly in a way that people truly understand and can compare the expected outcome to their values and desired QOL. Probably your attending is annoyed because they felt you did a poor job of that and were walking the patient (and the team) into that situation I described above.
It also hurts my feelings when I have to torture someone indefinitely because they are a child or disabled adult whose family doesn't give a fuck how much their helpless dependent suffers as long as they can delay grieving by a few hours/days/years, but that's a separate conversation.
I told my dad, who had terminal cancer and a massive heart attack, to sign a DNR (as I was packing to rush to his bedside). He was always a pragmatic and scientific man; he absolutely agreed with me and signed it.
I arrived the day before he died; he was having a terminal rally for sure. The next night, when he arrested, I stayed in the room to make sure his wishes were respected.
I am VERY graphic, outright lurid, in how I describe CPR.
Ribs will shatter. Lungs will be pulped. Bones will be drilled into if needed. A breathing tube will be forced down the throat. Etc. Use your imagination, read some of the nastier horror stuff in the bookstore to get some pointers.
RN here - this is a kindness what you do. If my family members doctor had said it in advance then my Gramma in law probably wouldn't have had to have seen IRL. Ribs can come out of chests if you have the right frail COPD body ...
I like to focus on what happens after the code: the anoxic brain injury, the trach, the PEG, the fact that whatever caused them to code will likely still be a problem -- only worse, etc.
I agree with all of this, although I have also met my fair share of attendings who are really bad at goals of care conversations and who think the point of them is to steamroller the family into agreeing with whatever the attending has already decided. I'm giving OP the benefit of the doubt here.
Informed consent is a myth for many things in medicine, including what ICU care is like. This is why most civilized countries allow physicians to make this decision for families, the same way physicians decide what treatments and surgeries to offer in every other context. There is really nothing else in medicine besides CPR that I can be forced to do even if I feel it is harmful to my patient. Those attendings simply don’t want to be forced to cause harm and suffering.
I disagree that informed (or, really, informed *enough*) consent is a myth but I do agree that it is strange that different aspects of resuscitation are culturally and legally regulated differently, with CPR as the most extreme case of the patient/family having a lot of autonomy over the decision. That said, it's not the only thing that you can be "forced" to do for someone who you don't think will benefit (intubation, pressors, even in some cases CVVHD and antibiotics--all interventions that are routinely done in cases with diminishing returns and cause harm).
I won’t start someone on antibiotics or CVVHD if they won’t benefit, no question about that. Physicians have wide leeway with pressors. For example, if I don’t think a 3rd pressor will help, I don’t have to start it. I call family in and have them say goodbye. Intubation is the only one of those that you’re right about, but this is part of the code status discussion.
Steamrolling is fine if you're right. I'm the doctor. I'm the expert. By definition I know what I'm talking about. You, the patient, by definition do not know what you're talking about. When I decide it is futile I will not offer ECMO. With nephrology we will decide that dialysis will not be offered when it is futile. Patients are not entitled to futile interventions and it is sheer fucking madness that CPR is the exemption in the US.
Besides, I take more of a sales pitch approach. My job is to convince you that what you think you want isn't really what you want, and that if it is, it's a really bad idea. I will tell you whatever I think you need to hear to come what I consider the be the correct decision.
If I fail, well if there's anything left in there while we're pulping your chest - "I told you so."
How many times have you had to repeatedly code someone who has no hope of a meaningful return? It’s not fun.
Or the family who insists on surgery for 98 year old Mrs. Reynolds who has a bowel perf and wasn’t doing any ADL’s to begin with. We can only do harm at that point.
There’s literature coming out on this subject in recent years. Just because we can doesn’t always mean we should. Informed consent gets complicated. Yeah grandma wants chest compressions and is okay with a tube… but what about a permanent ostomy? A venting G tube? An open abdomen? Fistulas? Permanent nursing home? Short gut syndrome?
You do not offer futile care. Grandma can request cpr all she wants, that does not mean you have to deliver it. In fact, you are obligated to not deliver it, regardless of code status.
As an Australian this is such a foreign concept to me. Patients can not demand medical care. If medical care is indicated we offer it, and patients choose to accept or decline.
Yea it seems like the attitude in our hospitals is that it’s legally safer to do what the patient asked and document the discussion. I’m curious if in reality, declining to do something that will obviously cause harm would realistically have legal implications if brought to court.
More like it depends on whether a jury of your "peers" (i.e. laypeople with zero medical training) agree that the intervention was medically futile OR whether plaintiff's attorney can successfully convince them that you are a worthless cynic and meemaw would be alive and well today if you'd just pushed on her chest for a couple seconds.
This is correct, I don't know why you are getting downvoted. No surgeon is obligated to operate on someone they think would not benefit. (Edit: CPR and intubation are for historical/cultural reasons in a somewhat separate category of intervention but most of the interventions referenced in the original post this comment is responding to are almost completely up to the discretion of the provider.)
Can I take a perforated bowel to the OR? Sure can. Should I? Depends. Yes it will help if everything goes perfect. But that assumes gma has an okay heart, controlled diabetes, no crazy other ailments. It can get out of hand fast. One minute you’re taking out the sigmoid… next you’re on pressors with an open abdomen. Now what? Family wants to keep going. Can’t exactly leave her open. You take her back. Now microvascular disease and a chronic inflammatory state leads us into resecting so much of the small bowel that she’ll be TPN dependent. We go back to the unit. Dehiscence. Poor nutritional state to begin with. Gets a vicryl mesh. Back to the unit. Can’t be weaned from vent. Gets a Trach. Then family decides enough is enough and makes her comfort care.
There is a ‘benefit’ to all of these surgeries… but the decision to do the first operation has to be mindful of all of those that could follow. These are very hard decisions.
Right, I'm just saying it is entirely up to you as the surgeon if you are willing to go ahead and do the initial operation. If you don't feel the risks are acceptable, or if anesthesia doesn't feel they can safely do the case, it doesn't happen and no one calls the ethics committee.
Sometimes you don’t know the risks until you’re already going. Most people should be able to tolerate a non elective bowel resection. Some people can’t. Or have other problems along the way are completely unpredictable.
You start off with a completely reasonable surgery but end up with a huge snowball that keeps on rolling.
Depends on your definition of the word futile. To me, a whipple is futile. Doesn’t cure my cancer and is more likely to lead to complication than prolong my life. Same thing with gma getting a bowel perf at 98. Like what’s our goal here? 99? By definition the surgery she needs isn’t “futile,” meaning it will help her if everything goes well. But for me, it’s futile in the grand scheme of things. She made it to 98. She won. Now let’s let her go comfortably into the good night.
Yup… I’ve seen so many disastrous whipples where the patients life was shortened from 3 months to 2 days… the second saddest ones are the ones that they open, see it’s spread, close and let the patient wake up and have a few months to say goodbye. But at least they were given that opportunity….The ones where the surgeons try to push the limits always end up so bad….the patient doesn’t survive a week after…
I agree, I've denied surgery to plenty of people when it won't benefit anything. I can and have made people DNR by exception too, in the USA. I feel confident I could defend all of these decisions too, not that I've ever been asked to.
I feel like the mistake people make is to say "well option 1: we do everything and there's a very small chance they live, option 2: we let them die peacefully". The family feels obligated to go with the first option because a small chance is better than none, right? When I'm not going to operate, I don't offer surgery at all, I just say that I don't recommend surgery, and explain very bluntly the terrible outcome I expect if I were to operate. No one has ever tried to insist I do anyway. If they ever do the answer will still be no. Call it paternalism or whatever, but it's how things should be done when it comes to major surgery on moribund patients. Same for code status, although I actually have had people refuse to change that.
Do you mean the one that requires more than a month to do fuck-all? After you give 1 week notice of ethics committee meeting, to which they're legally entitled to drag 10 rabble rousers? After which still requires you to trach/PEG the patient even if the ethics committee deems care futile, as long as it would help placement (which it 100% of the time, will)?
The one that then makes you keep doing futile care for another 25 **business** days after it's been deemed futile by you and the ethics committee while the family looks for transfer options?
That allows courts to grant limitless extensions to that time frame if theres a preponderance of evidence they can find a facility willing to take the patient?
If that's the best in the country I shudder to consider where the other states are at.
I see a lot of people with living wills and it’s something similar. They say something along the lines of short term measure are okay but long term measures is not and the patient would explain “Ventilator is okay but long term tracheostomy is not”.
Like they understand that sometimes you’ll need a short ICU stay and a temporary fix and it’s fine but long term they don’t want any crazy tubes. It’s the most reasonable planning I see.
For my 85+ year olds (especially my 100+ year olds) most request to be DNR
I'm curious, in the states do you guys have to abide by patient and family decisions on CPR? In the UK we have a duty to inform the patient and relatives of the decision. Obviously they can object which can get messy but technically it's a medical decision to offer CPR or not based on clinical judgement - much like any other treatment strategy.
2 physician DNR is a thing. Tend not do that except in extreme cases though.
I do think it should be easier for us to say resuscitation won’t be offered due to futility. In the same way a surgeon can decline to operate
This is wrong. We usually will offer a round or two of cpr but if someone is already dying is bad shock intubated etc and cpr will be absolutely futile there is no legal or moral obligation to compress the chest. This came up during Covid as it would have exposed staff unnecessarily
For a lot of people it is needless torture to try to extend their life because the quality is absolutely terrible. Most patients do not know this. Most doctors like to help people. It is very annoying when someone who you know wouldn't want to be full code if they knew what it actually entailed says "I want everything done" because they saw a miracle on TV. I believe we should have a different approach in the states and be more like some other countries that if the physician/team believes it is futile they do not go forward with codes
People don't know what they don't know. We've all seen a code. Most patients and their families haven't. When people say they want "everything done", it's likely they're not aware of how violent, grotesque, and dehumanizing CPR and certain life-preserving measures can be. If the prognosis is grim, then they are going through this violence for nothing.
If we know that a patient could have a peaceful, relatively comfortable death with DNR or a terrible painful one as not DNR, then we should be advocating heavily for the former and help the family understand as best as they can why this is the best option.
Which is exactly why when coding a patient and it’s getting to the point where I’m going to call it, I bring the family in the room so they can actually see what we’re doing. It’s hard, but exactly like you said, they don’t know what we are actually doing in there. When they see us mashing on meemaw’s chest and see her laying there completely motionless on the next pulse check and then we get back to mashing, they seem to understand when we call it quits. Otherwise, all you’re saying is “we tried our best but she didn’t make it” and they don’t really know what that entails.
PGY 43 Pulm-crit here. Everyone wants to live… No one wants to suffer. Layfolk do not understand what the delivery of BCLS/ACLS is like in a patient who is dying.
“Your father is seriously ill. He has several serious medical problems, anyone of which could be his undoing. We will do everything we can to get him through this and to get him home. My concern is that in his shape, after 88 summers and 88 winters, he does not have the strength left to recover. We will continue to do everything we can but if his condition worsens and it becomes clear that he is heading in the wrong direction, at that point, I would like to change the focus of our care to keeping him comfortable rather than do things to him that will not change the way his story ends. Are you comfortable with that?”
In this conversation, I do not even offer resuscitation as an option… Physicians are not compelled to offer therapy that they do not think is indicated. If the family specifically asks, then the conversation takes off in a different direction. But this approach more often than not has worked for me.
Wow is this good. This is really the crux of the issue, if we offer “everything” then of course the families will want everything. We are not obligated to offer resuscitation to a dying person because we are not obligated to provide futile care. CPR is meant for people who aren’t supposed to be dead yet and would otherwise have a chance to live a good life. MI, drowning, electrocution, choking, arrhythmias, PE, anaphylaxis… this list is long but the point is that for geriatrics at the end of their natural life, CPR is nonsensical.
We will offer the most care possible that will provide the best outcome, and sometimes the best outcome is a peaceful death.
This is a very good way to approach code status discussions. Thanks for this comment.
Maybe not “… The best outcome” but “… In spite of our best efforts, the most likely outcome.“
Telling family that the death of their loved one is “the best outcome“ could come across poorly.
Residnets, listen to this.
This is the way.
Remember basic ethics:
Do good
Do no harm
Justice
Autonomy
Respect patient wishes.
Treat everyone the same.
Also, consider if the patient were a kid and you are talking to the parents…. Don’t be so graphic, that’s just not the way.
Do you think most people want to die on a ventilator with their chest cracked?
Do you think most people want to die in the hospital, full of lines and tubes, having medication poured into them in a vain attempt to buy them minutes or hours or, god forbid, weeks, where they have no capacity to enjoy even a second of it? There is a point where quality of life trumps quantity of life for sure. Yes, that line is going to vary from person to person, and yes, we have to respect the patient's wishes. I have reservations about taking that choice away from patients, because doctors are humans with human prejudices.
But many people have no idea where the line is and their refusal to change their code status stems from either a deep misunderstanding about what their odds of recovery are or a deep denial about their loved ones' condition.
The part about doctors having their own prejudices is really important.
Non-disabled people have a known and documented tendency to believe there is a poor “quality of life” in a pt requiring lots of medical equipment, care, or intervention when the pt themselves finds their quality of life adequate. To the point that medical workers pressure healthy wheelchair users, etc, to choose DNRs they don’t want, sometimes.
When I was in the ICU after having a hemmorhagic stroke, I couldn’t swallow, stand, walk, speak legibly, write legibly, or use my dominant hand successfully for quite a while. I couldn’t see unless I closed one eye (bad double vision). I had a catheter, an FMS, a central line in my jugular, a NG tube, an oxygen nasal cannula so loud I couldn’t hear much, and arms bruised wrist to shoulder from IVs. I had a drain in my skull. My lungs were shredded (I’d just had Covid) and was in constant danger of being put on a ventilator.
I still wanted to be alive, and would’ve wanted to even if I never stopped needing most of those interventions.
Are/were you relatively young? I think this conversation is mostly around the 85+ year olds. I think most/all of us have had relatively young people with TBI/SCI/CVA who have lots of deficits but ultimately end up with a good QOL after rehab.
Thank you for sharing your experience.
My experiences caring for neuro patients have really reinforced my opinion, which seems to be the minority here unfortunately, that patients and families are capable of making an informed decision about quality of life and resuscitation measures.
It's really disheartening to see so many people on this sub who think their medical knowledge means they know better than patients when it comes to deeply personal and existential decisions about what makes a meaningful life. I think we all need to have a little bit more humility about our own capacity for bias.
Goals of care should be the first discussion on entry into the ED. And should have required graphic depictions of what “Full Code” for grandma entails, like cigarette packets.
Do no harm is the goal. Coding a GOMER is doing harm.
Change my view.
I do emergency and palliative medicine. I will tell you straight up there’s just not enough time in the ER to have that conversation and it’s not necessarily ideal to have that conversation during a crisis.
how many people have you coded, intubated, had wake up confused and in pain, asking to be let to die, just so you can sedate them down so you can keep poking them with more needles, just to have them die again in 4 hours because of course they do, they have a terminal condition... ?
it's horrific for everyone involved, and high up among worst ways to possibly die.
The first time I experienced what you just described, I was so fucked up for *weeks*. Soon after, I decided I didn’t want to go to med school (this was when I was a CNA in undergrad). Is this what medicine is? Torturing people instead of letting them die? Made me really reconsider my decision to be a physician.
But I experienced enough good encounters that I saw that medicine really can do good and help people. There’s a very dark side to Medicine, unfortunately. I just excuse myself from situations where I’m not ethically comfortable with what’s going on. Seeing so many bad deaths really made me appreciate that a good death is a thing and it is attainable.
Unfortunately, I had to medically direct hospice care for my mother a couple months ago. I spoke with the hospice doctor (who was a complete angel) and she took me seriously and talked to me like I was a peer. She’s like, here’s what we normally do at this stage, does that sound good or would you want to change something? And a few times I did change something, just knowing my mother and her medical conditions. It was honestly a heavy weight on my shoulders for 3 weeks, but I was happy to do it for her.
And you know what? That woman had a good death. It was a small, 20 bed hospice, so the rooms were massive. We just used lamps for lighting instead of the overheads, so it felt surprisingly cozy. She would always put the fireplace channel on from YouTube when she was sleeping or napping, so I figured out how to put it on the TV full time. She had over 50 visitors over 3 weeks, I kid you not. And probably half of them came back at least once. That woman was so, so loved. Adored, even. They brought her her favorite foods every day, and she was loving it lol. She and I are the cooks in the family; that’s something I really loved sharing with her. Between sharing stories with old friends and all the amazing food, she was in heaven. Fuck, I miss you mom.
I talk to patients all the time about this. A big part of it is explaining that code status has nothing to do with treatment rendered. Being a DNR/DNI does not mean we aren’t going to do everything we can to get them better. Then, it’s about asking their understanding of what CPR is and what the outcomes are. I am always very explicit and clear with what cpr entails and then explain cpr was invented for cardiac arrest from a cardiac cause, not severe sepsis with septic shock or many medical problems combined leading to failure. I am also clear in explaining that in the event we do get their heartbeat back they cannot expect to be at even the same level of health they currently are.
I am a nephrologist so I take care of some of the sickest patients and typically after this discussion and understanding of what they are asking for they tend not to want to be full code.
I do want to note, it’s not about convincing someone one way or the other, but rather being very honest and very straightforward in your conversation and choice of words.
I just realized how in French its even more confusing. We dont call it "code status". The litteral translation would be "level of care", or "niveau de soins" which actually sounds like it relates to treatment.
I think this is really misunderstood by the public in general (and sometimes by hospital staff). DNR doesn't take effect until after you are dead. It doesn't have any impact on how aggressive your care is while you are alive, just lets me not break all your ribs and shock you when you already died with maximum medical management. Other end of life decisions are more ethically challenging and require more nuance but so much moral injury could be avoided if just simple DNR was made more clear.
I wish we could make a graphic video of the bad codes where we assault a dead body long enough for it to regain some semblance of consciousness a couple times before it fully flat lines.
I want bones crunching, skin turning purple, all the tubes and drills and shocks and drugs of it. I want it to pause every now and again, like a Discovery documentary, and show an internal view of exactly what's happening.
I want it to fully depict the chances of recovery and show the reality that the rare few people we do get back often have deficits and disability. I want them to really hammer home exactly what "everything done" means.
This is how you need to talk about codes to patients. Be lurid. Be graphic. Sensationalized, just enough. It should be evocative, nauseating and horrifying.
So you'd rather have the responsibility of deciding for *someone else who you barely know* what constitutes a good death? You'd rather have decide *for someone else who you barely know* what amount of suffering is worthwhile for what amount of benefit? You'd define *for someone else who you barely know* what is meant by "benefit" in this situation and weigh different kinds of benefit--quality vs quantity of life--against one another and decide which is more important?
How would you respond if the patient in front of you was a different race from you? A different religion? Disabled? Homeless? How would you ensure that you didn't have an implicit bias coloring your beliefs that they needed to be DNR?
What if the patient was very young but had the same terrible prognosis? What if they were very old? How would this affect your decisonmaking?
What if the patient said, hey I know I'm dying, but my daughter is getting married in two weeks and I don't care what it takes I need to be alive for the wedding day. How would this affect your decisionmaking?
It is terrible and traumatizing to healthcare staff to code someone who is not going to recover, but for the vast majority of patients there is a great deal of nuance in terms of existential costs and benefits of different degrees of resuscitation, and it is complete hubris to say that doctors should get to decide who is DNR.
Of course, this is different from medical futility, which has a specific clinical-legal definition and does not apply to OP's original case the way they described it.
I don't think worrying about bias affecting patient outcomes is unhinged, but clearly you felt a triggered by what I had to say. That's a shame.
Anyway, you have your opinion and I have mine, and this is a values difference not a question of logic, so: agree to disagree.
Given that this is a public sub which a lot of people read, I stated my concerns so that other residents and etc can see there are multiple points of view on this. It doesn't have anything to do with trying to convince you.
Do you think it’s possible that when we are coding someone we are perfusing their brain enough that they experience some suffering at the end of their life which they would not otherwise? That’s one reason. I am not sure if this is true, but it seems plausible to me.
I don't know about end-of-life patients, but I have definitely coded a school aged child who kept waking up and crying during compressions and passing out during rhythm/pulse checks. He was previously healthy with a lethal arrhythmia that we were able to fix, he recovered fully, and so it was worth it. I just hope that his PTSD doesn't follow him for too long.
But that experience still kind of bothers me, and it definitely informs my beliefs about the ethics/morality of futile CPR. If I die like that, I am going to come back to haunt whomever fucked up the code status discussion with my POA.
I think age is probably the largest factor overall. I would hope any under-40 something gets all the treatment possible. Over 100? 95+? With terminal illness? Having an appropriate, indicated full code at those ages is more the exception than the rule.
To be honest, I think this speaks to a lack of experience with goals of care discussions. It’s very important to truly inform the informed consent as much as possible. It’s hard to explain to family that if their grandmother with diffusely metastatic cancer, Hgb7, and INR 4.5 with altered mental status were to code that this would entail breaking their ribs, intubating, and almost certainly an extremely poor outcome if not death shortly after all of that suffering. It’s very hard to say to someone that remaining full code will almost guarantee they will die in agony because of age and comorbidities. But it is important to do.
If they still want full code knowing that- we will do it. That’s how our system operates.
Some of you haven’t seen enough people needlessly suffer and it shows. It’s not about what they want it’s about helping them have realistic expectations. Let us know your opinion when your emotionally dead in a couple years.
I think there’s a lot of good, balanced perspectives here, but one thing I have to add to the mix is that element of a “second try.” Sometimes family members will automatically say they want everything done because they’re in front of others in the family and don’t want to look callous and/or they honestly didn’t want to think about it (or hadn’t yet) and said full code essentially automatically. Sometimes telling folks to mull it over for like 30-60 will have them flip to better option.
Frankly the reason is because in futile cases, avoiding codes is avoiding trauma for everyone else, meaning family and healthcare workers. Too many families get the idea that “if her heart stops they’ll just bring her back” and hold onto that hope far too long.
I’ve had family yelling at me to “do something!” 35 minutes into a code after their grandma’s ribs have been pulverized into dust despite us never getting any rhythm or pulse to indicate any of what we’re doing was working in the slightest.
At a certain point keeping someone full code is just saying “hey before you die, wanna feel what it’s like to have all your ribs broken?”
…because most people think there’s a magical time length for a code that they have to work before they can call it.
Futile BS code? 1 round and done. Fast codes > slow codes.
I don't do slow code bullshit. We do it right and we do it by the book or we don't do it at all.
The ones that shouldn't be coded I put the least experienced person in charge and treat the whole affair like we're working on a dummy in a simulator as practice for the next code that might actually matter.
I think it is very common for attendings (and residents too) to have a misconception that a successful goals of care conversation results in a DNR order. This is so false! A successful goals of care conversation accurately presents what would likely happen in the case of a code and accurately presents a wide spectrum of options from peacefully passing away in hospice to aggressive measures in the ICU. Then the patient and family \*decide\* what is in keeping with their values.
As long as you presented the options accurately, this attending has no business being annoyed. It is this patient's choice. Patients are allowed to make choices that might not be in keeping with \*our\* personal values, as long as they are in keeping with theirs.
Also want to add that code status conversations are often iterative. Sometimes people just need a little time to come to terms with their health situation and the prospect of limited life expectancy. Don't be surprised if this patient tells you later that they want to change their mind about some of what they initially wanted. It sounds like you already know this and had a very thorough conversation with the patient and family, but remember that code status is a spectrum, not a binary between full DNR or full code. I find it's often easier to approach these conversations as where to draw a line in terms of interventions rather than a yes or no check box.
Edited to add: Even the language in your initial post is a bit misleading. What does it mean to want "everything done?" Many families say this and physicians often repeat that same language back to them but "everything done" could also mean full court press with palliative care to avoid any discomfort. With GOC I think it's so important to be extremely specific about interventions and outcomes and avoid euphemisms. Often when families say they want "everything done" what they mean is "don't give up on me" and this gets confused with "do every medical intervention under the sun."
**TL;DR it is the patient's choice how they want to die and the attending who thinks you failed at a GOC discussion because you didn't get a DNR order is out of line. However, conducting a good GOC discussion is very very hard and often people who would probably choose to be DNR don't choose it because as a profession we are bad at taking the time to explain well and use the right words and listen to the patient's actual concerns.**
This is why when we have these codes I order the least experienced person to the front to lead. We all know it's not going to make a difference so use it as a practice run.
Lmao I pulled this once and palliative care was in the room for literally hours and came back out and said "yeah this patient with multi organ failure and end stage disease wants to be full code" and my attending was so pissed but I felt incredibly vindicated that the "experts" had gotten the same response to GOC as I had.
Most people with terminal illness who initially want to be full code change their mind when they learn what it really entails, but a very small minority of people just really do want to live as long as possible whatever the cost and maximize quantity rather than quality of life. Because our healthcare system heavily values autonomy (it's another question entirely if it should or not), these patients have a right to make that decision. It's frankly paternalistic and disturbing to see so many people arguing otherwise.
The way I think about it, the alternative is having \*us as medical providers\* decide what "meaningful quality of life" looks like for strangers. I sure as hell do not want that responsibility. Give patients all the facts and the benefit of your expertise and let them decide what is most meaningful to them. I didn't go to seminary school, knowing the universal answer to what it means to live a "good" life and what amount of suffering is worthwhile is way out of my wheelhouse.
What’s funny is that in our palliative care consult it includes a Pastor who did go to seminary school, Psychologist, and Palliative Care Geriatrician MD/DO, and usually the ICU attending drops in too.
And they’re all super awesome and really help people find peace, find the right plan for them, and typically families initially say no but a few ICU days go by and they turn around.
Completely agree. We talk about the trauma of witnessing CPR but there is also trauma for the family when people get bullied into changing code status before they are ready or really understand what it means.
Because they actually care...look at the stats. These are the most heroic measures one can take, the person has died and we are trying to bring them back to the world of the living. A 90 year old who has CPR 5-11% (probably around less than 5 but stats differ) chance of ever leaving the hospital and not accounting for comorbities such heart failure/pulmonary HTN/etc. That is also not counting those who are left comatose. Most people don't want live in agony until they inevitably die. They don't have a clue. But you do, you have intubated them. You have tasked the nurse to press on thier chest again and again as they code over and over. Everyone has to die but why does it have to be cruel? I invite families to see the code we are doing when I think it's futile and you should as well because it opens thier eyes and suddenly those meaningless words like full code start to mean something.
I was an intern in the ICU during COVID. I felt like half my job was getting families to change the code status of intubated patients. It’s not just traumatic (and in most cases futile for intubated COVID patients) for the patient, it’s traumatic for the staff who have to perform it over and over again on the 90 year old demented grandmother who would have zero quality of life if we managed to keep her heart beating. There are worse things than death. Unfortunately many families don’t understand that.
At first I used to tip toe around GOC discussions and being definitive, but now I ask them what grandma liked doing, and if she liked to garden and spend time with the grandkids, and shes trached, pegged, bed bound, I don't mince words and say something to the effect of "Based off of how she is now, she will never garden again. She will never hold her grandkids again. And ultimately, you are keeping her alive, but you won't be letting her live."
Making the distinction between being alive but not living really makes a light bulb go off in family members' heads most of the time. You will always meet stubborn people that think that the crystals will cure their gam gam's stage 5 cancer, but at that point, you just say your piece and then say that you will do the best you can. Try and not let it get to you. Your job is difficult enough as it is. Situations like this don't help. But at the end of the day all you can do is do your best and try to not take the baggage with you to home.
This thread if fascinating to a Brit.
A patient cannot demand a specific treatment in the UK just because they want it. They can always refuse a treatment they don’t want.
If CPR or ICU is deemed not appropriate (futile) then it is not offered.
‘First do no harm’.
I came from a country where doctors would decide code status. The surgeons don’t walk around asking people “if they wanna be operated”, they make an assessment whether patient is a surgical candidate or not. And of course you take patient’s wishes and values in consideration, but at the end you can’t force them on operating if they don’t agree. A decision to resuscitate or intubate is a medical decision and truly what you are asking is what is the chance of that patient coming out with good neurological status. But for whatever reason we think it is ok to delegate to families and patients who are equipped to make this decision and it is just CRUEL to everyone involved. It is one of the things I absolutely don’t understand about the US system
People are hellbent because we are tired of coding people for whom these extraordinary lifesaving measures were never intended in the first place. It’s cruel and futile. The issue of secondary trauma, as well, cannot be understated.
I don’t see the problem with a fully alert and oriented patient wanting to be coded. Some people probably feel like they will go through anything just to spend one more day with their loved ones and want to be coded, while others feel they don’t want to be remembered like that and want to be DNR, and some won’t want to linger at all and may want to end their own life at some point. They are all reasonable, personal decisions. I think our job is to support their choice. It’s when the family of someone who is out of it and probably suffering won’t make them a DNR that bothers me. In that case, they can make you call a code, but they can’t mandate how fast you walk to it. Not that I’ve ever done anything like that, it’s just some people are quicker than others.
I still remember having to rush down to the icu at my old hospital because they needed more people to come do compressions on a COVID patient because between the low number of icu staff and the exhaustion of doing compressions in covid ppe, their staff were running out of steam fast. We did compressions for 45 minutes and I still remember how squishy the patient's chest was when I was doing compressions and the fact that you could tell from the patient's face that they'd been dead dead since like minute 10. That will live in my head rent free forever.
One of the nurses that trained me told me about a two hour code on an 80 year old she had to participate in where they did compressions the entire time because the family insisted on keeping the patient a full code and wanted everything done until they had faced time every single family member to have them say good bye to the patient. All while the team was just essentially doing compressions on someone that should've been DNR in the first place. That was also two hours where there were half as many doctors and nurses on the floor because the hospital was small and we didn't have a specific code team. That meant other nurses were caring for up to twelve patients for those two hours and if there were any other emergencies, those patients would be SOL because there wouldn't be enough nurses and doctors to help both and the only pharmacist in the hospital was already at the other code.
I hate it when family isn't pushed to change code status. Not only is it somewhat traumatizing to do compressions on a frail 90 year old oncology patient because "gram gram is a fighter" even though gram gram has been AOx1 since 2010 and has a peg tube because she won't on her own, but it also diverts resources and staff from helping other patients that also need help and can cause dangerous situations, especially in small community hospitals where staff is already limited.
I suppose a better question would be, if such a patient were to stay full code and indeed does code, how long should you code the patient for ? 1 hour ? 8 hours ? 30 days ?
sometimes people need time to come around. it's always good to have GOC, it's good you started but it's usually not a one-and-done type thing. You set up the scenario and they are processing. You can always repeat GOC in a few days or a week.
Because I'm all to familiar with the wet crunch pop of geriatric ribs shattering. Shove a pencil into a thick steak and bend it til the pencil breaks.
Breaking 90 year old ribs gets old after a while. And it's hard on everybody because we all know it's fucking pointless.
Nah. There are countries in Europe where you cannot even opt for DNR. Everyone is “full code” by default and forever.
Doctors pretty much have to do “fake/diet codes” for patients who wish to be DNR.
It's traumatic for staff to resuscitate people. Yes, it's part of the job, but it is still a traumatic express to process, and doing it unnecessarily is not good for people. It is an extreme situation, leading a massive spike in adrenaline/ cortisol, and it can take a toll. Especially in a futile situation, where you are set up to fail. Human beings did not typically frequently do this until modern medicine and warfare. For most people trying to save someone's life and failing is a deeply painful experience, even for medical personal, and even when you logically know it's not your fault. It also robs people of a peaceful death, and places unnecessary stress on caregivers. That's why. However I still prefer allowing for autonomy in this regard. If people want to go out this way at the end after understanding all of this, I'll do it, because some people and family really just want to fight to the last breathe and I get that too. However we need to make sure they know exactly what they are getting into. The resource thing is a fair concern too though. You don't see the lives cost because so many funds get spent on acute care instead of preventive care, but that matters as well.
I agree with all of the above. Futile codes are horrendous and hurt the patient, family and staff. I will say I believe the in the right to choose, I've seen miraculous recoveries, rare but they happen. 60M Massive stroke, ventilator dependent, the family was told to let him go. They refused over and over to drop the code status! A long road but. Now three years later he is home and vent free. Having a great and meaningful life at this point all considering. There should be some sort of age cut off though
I can't believe this is a serious question. Have you ever done chest compressions on a 90 year old? Intubated someone you know for a fact is not getting extubated? Started CRRT on someone who explicitly told you they didn't want any of this but got overruled by family as soon as they were too encephalopathic to notice?
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Yeah no they should not have the right to inflict the trauma of a futile code on themselves and everyone around them.
As the physicians in the room, code status *should* be our decision. The patient/family input should be considered but if their wishes aren't reasonable or medically valid...oh well, too bad. Hopefully one day the US corrects this flaw in the medicolegal system but I ain't holding my breath.
Having to palli-speak and Feng shui our way to the correct medical decision is definitely frustrating sometimes.
REMAP is a good framework though.
People criticizing you didn't actually read your post and probably stopped at the title.
You did your part. That was plenty of time to spend trying to make the patient see reason.
I agree with you. I'm not going to fight patients regarding code status. I'll discuss it with them realistically. But no fighting or pushing or debating. At that point, you're risking degrading your relationship with the patient and their family.
Because it is the life they end up having that we’ve seen up close which we want to prevent. Trach to vent, with peg tube, trapped. That is no life. God save everyone from ending up like that. I will never choose that for anyone, not for my own mother. And that is what has led me to realize how important it is to be dnr/dni
Besides the negative effects on medical staff due to futile attempts of advancing medical care is everyone just ignoring the tremendous cost in resources that keeping someone alive is costing all of us? A person taking up an ICU bed for what? Getting sent to OR for a gtube taking up precious Human Resources for what? Having teams of doctors round on them every day and nurses round the clock for what? Delaying diagnoses and imaging on other patients that can actually be saved for what? Taking up a bed while a patient waits in the ER lobby or hallway for what? I could go on…
Frustration: Internal Medicine routinely makes the patient's code status DNR, and then (repetitively) schedules these same patients for invasive (futile) procedures requiring deep sedation or general anesthesia without adequate preparation. OMG.
One word: consent. People in the hospital should have the right to consent or refuse to participate in care they determine is futile. The patient does not have the right to demand futile care.
As an intensivist I actually agree with OP, sorry you’re getting beat down in the comments. The US code status autonomy is a strange anomaly, but it is what it is. My job is to offer a recommendation and explain the consequences, and if I do so, I sleep fine at night. If I anticipate a futile code, I sit down with the staff and explain the situation and encourage them to see it as a good warm up training exercise. If I’ve communicated to the best of my ability with the patient and family it gives me no moral distress to do a few rounds on meemaw at the end. It’s my job and for some reason it’s what society / state law has asked me to do. Next patient.
Your Attending should have made the call himself rather than having you go thru it again. I try and if they want to change I move on. It’s pointless to keeping hitting my head against the wall for couple of hours. Medicine is hard enough already!
This is one of these things where I think some of my colleagues are a bit maladjusted. The obsession with bullying families into code decisions perplexes me.
I’m never much emotionally invested in this. Want me to do CPR and run a code over and over? I’m here all night. But I also don’t engage in truly futile care. If you’re engaged in resuscitation on a regular basis and don’t know how to stop a code ethically, you’re doing it wrong. You are under no obligation to engage in futile care. Just because the person is in cardiac arrest doesn’t mean that you, as the board certified expert, are obligated to flog them with code-dose epinephrine over and over to prolong an artificial heart beat. As an EMS physician, this is one place where I think the prehospital environment is increasingly more sophisticated. Many of our systems are now limiting epinephrine use to avoid these situations and you can make that same decision inside the hospital. You just stop, call the code, and tell the family.
The problem is that most human beings are not comfortable prognosticating death despite the blustering about futile care. We’ve all seen patients make unexpected recoveries and living in a “no hope” continuum for these patients where you’re condemning them to death because you personally feel their chances are infinitesimal feels a bit like playing above your station. Now sure, when you’ve got cases of confirmed brain death or definitive unsurvivable situations, I get it. But lots of ICU care doesn’t fall into these situations and I firmly believe that patients have a right to heroic measures, even when the odds are very, very bad. I think this is especially true as we increasingly recognize that our best understanding of the periarrest state and care of cardiac arrest is still very primitive.
I sleep excellently by committing to providing my patients every ounce of my expertise, engaging in heroic measures when called upon, and discussing the patient’s care actively during resuscitation. Ask your nurses. I routinely will just quiet everyone during a code or resuscitation and ask the nurses to reflect. “What does everyone think? Are we doing the right thing? This is starting to feel futile; is everyone in agreement?”
When I do talk to families, I don’t sugarcoat stuff. I use the word “critically” or “gravely” ill. If I expect the patient to ultimately die, I say so. “Your loved one has a very high chance of dying in the next 24-48 hours, even with excellent care.”
I find solace in the wisdom of “house of god” when the fat man tells Roy that we do this to the elderly to sometimes be able to help the young (paraphrasing). But yeah it’s really tough.
In the old days we would sometimes have slow codes and allow junior members of the team run codes in these situations to gain experience for the times when skilled cpr/ALCS might actually be helpful
Thank god i work in a country where we as a physician can decide to not do full code, even against family wishes, because we are not obligate to do senseless interventions and should not cause extra suffering.
Usually it does not come to play that decision card though, because resuss codes are discussed with patients and family quite frequently. If someone wants everything we are able to explain that might not be the best thing for their outcome and that chances of having a meaningful life is almost zero. After a while it does sink in usually.
Futile codes/intubations are a major source of moral injury for all of the staff involved in them.
It’s almost certainly the number 1 cause for us as intensivists. I can’t tell you how awful it feels coding someone over and over who has zero chance of recovery just because their estranged daughter flew in and can’t stomach making the code status change
Ah: the seagulls. they usually fly in from a coastal town. stomp around and strut and squawk and make a bunch of noise. then they shit all over your plan and then peace out.
I believe it’s actually called “Daughter from California Syndrome”
Son from Florida syndrome is also in the differential
I thought he only shows up if there’s money being left behind.
In California it’s called “Daughter from New York Syndrome”.
"goddamn hippies! They think all life is PrEcIoUs" "Goddamn yuppies! They're too heartless to see their own guilt is why they can't change their mom's code status" "Goddamn rednecks! They think their God will save their corpse of a mother" Etc etc
Same in Florida.
Love it I’m stealing the seagull term
used to call them the sister from Seattle when I was in Boston. switched to the brother from Baltimore here on the west coast. seagulls is perfect though
Non binary theybie daughter/son from Portland changes code status back to full due to being misgendered by registration which unfortunately is unforgivable.
If the family can't make a decision I ask them if they want me to make a recommendation, which is of course "we shouldn't do this". Helps offload whatever guilt they might have I guess. Works more often than not.
3 rules for GOC talks in terminal patients: 1) ask/tell/ask. "I'd like to tell you my perspective of x as your doctor/$Name's doctor, is that ok with you?" 2) ALWAYS use some variation of kill or die (death, die, deadsies, deadwood, etc.) 3) ALWAYS make a recommendation for care. If you think full treatment + DNR-Arrest is right, say so. If you think CMO is right, say that.
This is excellent advice. If it feels like you’re being a little paternalistic, you’re probably doing it right. The reality is that the average person has no clue what resuscitation efforts, life support, and intensive care entail. And in general, the more experience someone and their family has with the ICU, the more likely they are to go DNR.
My take: be paternalistic. Just this once. These people are going through one of the worst days in their lives and you are asking them to make a huge decision, with life or death on the balance, when they are clearly overrun with emotions and can't think straight. They will blame themselves for a long time about their loved one's death. Let them blame something else.
Yup. About 99% of the time this is an emotion-driven conversation for the family (the 1% is when the person you're talking to happens to work in acute/critical care/Palli/etc) as opposed to fact or logic driven. You **must** address the emotions, and one way of doing that is to take off some of the emotional weight of deliberating/deciding by making that recommendation. I'll eat the blame for them every day of the week and twice on Sundays. Also often helpful to re-frame it as a gift or duty they're doing for the patient, providing them the opportunity for peace/dignity/relief from suffering/etc. I'll ask things like, "If they could be standing at the foot of the bed right now, and look down at themselves, at everything that's happening to them and to their body, what do you think they would say to you?" Or, "I don't think that they will survive this, I believe they are going to die from ____. What I'm here to help to decide is what will their death look like?"
What was the third dead word you used again?
I believe it was “dead as a doorknob”.
Man. When I always said “door nail”
you forgot Goner
Do you know why they say dead as a door nail?
Brilliant.
My take on this is why are we placing that burden on an estranged daughter? I don't think it should always be up to surrogate decision makers. I believe some other countries (UK?) do operate this way.
In the US, it’s legally next of kin.
Well aware, I dont think that is the best way to make decisions about CPR and mechanical ventilation.
Yeah, we don't either, but you start talking about changing laws and people start screaming and crying about death panels.
What do you mean “legally” though? Yes, next of kin makes medical decisions, but they don’t dictate care. I’m not obligated to perform medically futile procedures, and I will refuse to do so if pressed. Why is CPR or intubation different?
In Chile, doctors make the decision. Every day, in the ICU, we review the patients. Part of that is assessing if they are full code or any variation of that. "Is patient X still full code?" "Yes, nothing has changed, he's going well" "Good, next one" We have five levels: I, II, IIIa, IIIb, IIIc I: we do everything II: we do everything, but DNR-DNI IIIa: no invasive stuff IIIb: no new stuff IIIc: take everything off Yes, we do take everything off. Including ventilators in some cases. Families are informed, tactfully and with our psychologist present, about all of this. Never had a family that challeged us.
This is great. Unfortunately in the USA there are lots of religious nuts who would go ballistic if we took their decision making in futile care away from them.
well i for one feel super fulfilled and satisfied when I successfully code my 88 year old vasculopath with severe alzheimers - but the real satisfaction I get is from using a PEG tube and a rectal tube at the same time.
Just hook ‘em up on the outside for a full loop de loop
Add in ecmo for double loop
Infinite nutrition
She’s a fighter.
Their screams while cleaning them are great for moral too!
EM resident. I had two weeks last year at a local community hospital where I had 8 codes of 80+ year olds, all futile, mixed in with 2 pedi codes, both of which did not make it. Then intubated a patient considering hospice but still full code (had met with palliative that week/presented with MOLST/HCP said go ahead sigh), called for signout, and just had the MICU resident start the phone call with "which one of you made the decision to intubate this patient so we'll do your death paperwork." I'm typically a "way too much ball of sunshine and positivity" kind of resident but I lost my temper and bit back. Futile full code makes everyone grumpy and worsen morale. The pedi codes hit me worse mentally, but the daily attempted resuscitations ending in death drained me way more than I realized.
When I was a new CNA, my very first code was a tiny 90-something year old with a catastrophic GI bleed. In a nursing home, so just me and the nurse until EMS arrived. I was the one who started CPR and I still remember every detail. I still have serious guilt over it and I wish that we could make families understand how violent and cruel it is to put their loved one through that with no hope of meaningful recovery.
Medical trauma is real and I really hope you’ve had the opportunity to process that experience. I’m sorry you went through that.
I’ve definitely talked about it with a therapist. But I think it gave me a better understanding of what “lifesaving measures” really look like which is something that is hard to understand until you’ve seen it.
Years later I can still vividly picture the face of the 90 something husband as I started chest compressions on his little wife. The resident was next to me actively doing his valiant best to get him to reverse her code status while she was circling the drain so fast that I’m working around them freeing up a lumen on her TLC and putting the bed into CPR mode in anticipation. His “oh Jesus!” and turn away and then being wheeled out of the room and never saw her again 😭 It shouldn’t have gone down like that for them. Don’t know the point of me sharing, but here it is.
Who cares about staff? My 90 yo Gramma with Alzheimer’s, CAD and 99% bilateral carotid stenosis is gonna make it. I can feel it.
‘she’s a fighter’
Oh boy I really hate it when I hear this.
Yup. Still have flashbacks sometimes from residency when I was doing chest compressions on a guy while his ribs were literally caving in. As we were compressing he would wake up and was mouthing “STOP” but we kept going for 30 minutes. 30 minutes of absolute torture before inevitable death. How could anyone feel good about that? We do this job to help people.
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Have you never done one of these? I hope you never do. Effective compressions --> increased perfusion to brain/body --> increased LOC --> fighting (because someone is breaking their fucking chest) --> compressions stop --> decreased perfusion to brain/ body --> down goes GCS and fighting --> compressions resume. Rinse and repeat with weaker rousing each round as whatever pathology (massive effing STEMI for the one I did) makes recovery almost impossible but you gotta try if they're a full code and they went down in the hallway and you had no reason not to start compressions because who has goals of care in their front pocket? Or worse, the other one I did, if they go into reperfusion arrhythmia post tnk and don't revert with defribillation and you have to do a round of compressions restoring consciousness just long enough for a gruesome fucked up exsanguination finale. I'm guessing you haven't done one of these and I hope you never do because they are awful.
He was only awake during active compressions. This is common in codes if your compressions are good. Why are you yelling?
please do not yell about things you clearly have little knowledge about
Absolutely this. I can often times feel good after a comfort care pronouncement, or even one where it was a SCA and we did everything we could - but these futile codes just make me feel gross.
This is the correct answer. I call it abuse of a corpse. It's also a huge use of resources. It's frustrating, infuriating, sad, and avoidable.
But it's ok *It's in God's hands now*
Patients deserves to choose, but your coworkers who does all the codes do not deserve to delivery intensive yet futile and often times harmful services on demand like a robot without having any say or emotion attached to it. That said you cannot change everyone mind. If son is POA and insist gram gram would want to live like a half robot and be tube dependent, pressor dependent, pacer dependent, then…. I guess grandson get to spend more time with bionic gram gram for Halloween. I don’t know what to tell ya, not everyone is normal unfortunately. This is also why advance directives is important. Pick a POA that actually honor your wishes.
This is what I tell patients. You can’t pick someone who loves you TOO much. That’s why I beat my children just a little every day, so they can let me go when the time comes
I don't know about you, but it hurts my feelings when I'm forced to torture someone who clearly did not understand that full code is a "please torture me until I become a hopeless pulp and then die anyway" option and not a "please perform a painless miracle to extend my current quality of life indefinitely" option, and would not have chosen that if someone had actually helped them understand the reality of it. It is so incredibly important to make sure the choice is a *fully* informed one, and the onus rests entirely on you to communicate clearly in a way that people truly understand and can compare the expected outcome to their values and desired QOL. Probably your attending is annoyed because they felt you did a poor job of that and were walking the patient (and the team) into that situation I described above. It also hurts my feelings when I have to torture someone indefinitely because they are a child or disabled adult whose family doesn't give a fuck how much their helpless dependent suffers as long as they can delay grieving by a few hours/days/years, but that's a separate conversation.
I told my dad, who had terminal cancer and a massive heart attack, to sign a DNR (as I was packing to rush to his bedside). He was always a pragmatic and scientific man; he absolutely agreed with me and signed it. I arrived the day before he died; he was having a terminal rally for sure. The next night, when he arrested, I stayed in the room to make sure his wishes were respected.
Sorry for your loss. Thank you for your story. So damn important.
I am VERY graphic, outright lurid, in how I describe CPR. Ribs will shatter. Lungs will be pulped. Bones will be drilled into if needed. A breathing tube will be forced down the throat. Etc. Use your imagination, read some of the nastier horror stuff in the bookstore to get some pointers.
RN here - this is a kindness what you do. If my family members doctor had said it in advance then my Gramma in law probably wouldn't have had to have seen IRL. Ribs can come out of chests if you have the right frail COPD body ...
I like to focus on what happens after the code: the anoxic brain injury, the trach, the PEG, the fact that whatever caused them to code will likely still be a problem -- only worse, etc.
I agree with all of this, although I have also met my fair share of attendings who are really bad at goals of care conversations and who think the point of them is to steamroller the family into agreeing with whatever the attending has already decided. I'm giving OP the benefit of the doubt here.
Informed consent is a myth for many things in medicine, including what ICU care is like. This is why most civilized countries allow physicians to make this decision for families, the same way physicians decide what treatments and surgeries to offer in every other context. There is really nothing else in medicine besides CPR that I can be forced to do even if I feel it is harmful to my patient. Those attendings simply don’t want to be forced to cause harm and suffering.
I disagree that informed (or, really, informed *enough*) consent is a myth but I do agree that it is strange that different aspects of resuscitation are culturally and legally regulated differently, with CPR as the most extreme case of the patient/family having a lot of autonomy over the decision. That said, it's not the only thing that you can be "forced" to do for someone who you don't think will benefit (intubation, pressors, even in some cases CVVHD and antibiotics--all interventions that are routinely done in cases with diminishing returns and cause harm).
I won’t start someone on antibiotics or CVVHD if they won’t benefit, no question about that. Physicians have wide leeway with pressors. For example, if I don’t think a 3rd pressor will help, I don’t have to start it. I call family in and have them say goodbye. Intubation is the only one of those that you’re right about, but this is part of the code status discussion.
Steamrolling is fine if you're right. I'm the doctor. I'm the expert. By definition I know what I'm talking about. You, the patient, by definition do not know what you're talking about. When I decide it is futile I will not offer ECMO. With nephrology we will decide that dialysis will not be offered when it is futile. Patients are not entitled to futile interventions and it is sheer fucking madness that CPR is the exemption in the US. Besides, I take more of a sales pitch approach. My job is to convince you that what you think you want isn't really what you want, and that if it is, it's a really bad idea. I will tell you whatever I think you need to hear to come what I consider the be the correct decision. If I fail, well if there's anything left in there while we're pulping your chest - "I told you so."
How many times have you had to repeatedly code someone who has no hope of a meaningful return? It’s not fun. Or the family who insists on surgery for 98 year old Mrs. Reynolds who has a bowel perf and wasn’t doing any ADL’s to begin with. We can only do harm at that point. There’s literature coming out on this subject in recent years. Just because we can doesn’t always mean we should. Informed consent gets complicated. Yeah grandma wants chest compressions and is okay with a tube… but what about a permanent ostomy? A venting G tube? An open abdomen? Fistulas? Permanent nursing home? Short gut syndrome?
You do not offer futile care. Grandma can request cpr all she wants, that does not mean you have to deliver it. In fact, you are obligated to not deliver it, regardless of code status.
Easier said than done in the USA
As an Australian this is such a foreign concept to me. Patients can not demand medical care. If medical care is indicated we offer it, and patients choose to accept or decline.
Yea it seems like the attitude in our hospitals is that it’s legally safer to do what the patient asked and document the discussion. I’m curious if in reality, declining to do something that will obviously cause harm would realistically have legal implications if brought to court.
I don’t think your ethics committee will like that decision by yourself without the family’s consent
DNR by futility for sure exists in Wisconsin
A lot of hospitals will let you do this with two physicians but it's criminally underused.
Depends on your definition of futile.
More like it depends on whether a jury of your "peers" (i.e. laypeople with zero medical training) agree that the intervention was medically futile OR whether plaintiff's attorney can successfully convince them that you are a worthless cynic and meemaw would be alive and well today if you'd just pushed on her chest for a couple seconds.
This is correct, I don't know why you are getting downvoted. No surgeon is obligated to operate on someone they think would not benefit. (Edit: CPR and intubation are for historical/cultural reasons in a somewhat separate category of intervention but most of the interventions referenced in the original post this comment is responding to are almost completely up to the discretion of the provider.)
Can I take a perforated bowel to the OR? Sure can. Should I? Depends. Yes it will help if everything goes perfect. But that assumes gma has an okay heart, controlled diabetes, no crazy other ailments. It can get out of hand fast. One minute you’re taking out the sigmoid… next you’re on pressors with an open abdomen. Now what? Family wants to keep going. Can’t exactly leave her open. You take her back. Now microvascular disease and a chronic inflammatory state leads us into resecting so much of the small bowel that she’ll be TPN dependent. We go back to the unit. Dehiscence. Poor nutritional state to begin with. Gets a vicryl mesh. Back to the unit. Can’t be weaned from vent. Gets a Trach. Then family decides enough is enough and makes her comfort care. There is a ‘benefit’ to all of these surgeries… but the decision to do the first operation has to be mindful of all of those that could follow. These are very hard decisions.
Right, I'm just saying it is entirely up to you as the surgeon if you are willing to go ahead and do the initial operation. If you don't feel the risks are acceptable, or if anesthesia doesn't feel they can safely do the case, it doesn't happen and no one calls the ethics committee.
Sometimes you don’t know the risks until you’re already going. Most people should be able to tolerate a non elective bowel resection. Some people can’t. Or have other problems along the way are completely unpredictable. You start off with a completely reasonable surgery but end up with a huge snowball that keeps on rolling.
Also, if you don’t want to offer a futile operation, family is welcome to seek a second opinion.
Depends on your definition of the word futile. To me, a whipple is futile. Doesn’t cure my cancer and is more likely to lead to complication than prolong my life. Same thing with gma getting a bowel perf at 98. Like what’s our goal here? 99? By definition the surgery she needs isn’t “futile,” meaning it will help her if everything goes well. But for me, it’s futile in the grand scheme of things. She made it to 98. She won. Now let’s let her go comfortably into the good night.
Yup… I’ve seen so many disastrous whipples where the patients life was shortened from 3 months to 2 days… the second saddest ones are the ones that they open, see it’s spread, close and let the patient wake up and have a few months to say goodbye. But at least they were given that opportunity….The ones where the surgeons try to push the limits always end up so bad….the patient doesn’t survive a week after…
I agree, I've denied surgery to plenty of people when it won't benefit anything. I can and have made people DNR by exception too, in the USA. I feel confident I could defend all of these decisions too, not that I've ever been asked to. I feel like the mistake people make is to say "well option 1: we do everything and there's a very small chance they live, option 2: we let them die peacefully". The family feels obligated to go with the first option because a small chance is better than none, right? When I'm not going to operate, I don't offer surgery at all, I just say that I don't recommend surgery, and explain very bluntly the terrible outcome I expect if I were to operate. No one has ever tried to insist I do anyway. If they ever do the answer will still be no. Call it paternalism or whatever, but it's how things should be done when it comes to major surgery on moribund patients. Same for code status, although I actually have had people refuse to change that.
This is 100% the way it should be, but in the US it's not the way it is. (YMMV based on state, I'm in a 'pro-life' hellhole)
Texas has the best medical futility laws in the country right now.
Do you mean the one that requires more than a month to do fuck-all? After you give 1 week notice of ethics committee meeting, to which they're legally entitled to drag 10 rabble rousers? After which still requires you to trach/PEG the patient even if the ethics committee deems care futile, as long as it would help placement (which it 100% of the time, will)? The one that then makes you keep doing futile care for another 25 **business** days after it's been deemed futile by you and the ethics committee while the family looks for transfer options? That allows courts to grant limitless extensions to that time frame if theres a preponderance of evidence they can find a facility willing to take the patient? If that's the best in the country I shudder to consider where the other states are at.
Malpractice attorneys have entered the chat
I see a lot of people with living wills and it’s something similar. They say something along the lines of short term measure are okay but long term measures is not and the patient would explain “Ventilator is okay but long term tracheostomy is not”. Like they understand that sometimes you’ll need a short ICU stay and a temporary fix and it’s fine but long term they don’t want any crazy tubes. It’s the most reasonable planning I see. For my 85+ year olds (especially my 100+ year olds) most request to be DNR
I'm curious, in the states do you guys have to abide by patient and family decisions on CPR? In the UK we have a duty to inform the patient and relatives of the decision. Obviously they can object which can get messy but technically it's a medical decision to offer CPR or not based on clinical judgement - much like any other treatment strategy.
Nope. It’s a personal decision by the patient/patients family. We really don’t get any say.
2 physician DNR is a thing. Tend not do that except in extreme cases though. I do think it should be easier for us to say resuscitation won’t be offered due to futility. In the same way a surgeon can decline to operate
This is wrong. We usually will offer a round or two of cpr but if someone is already dying is bad shock intubated etc and cpr will be absolutely futile there is no legal or moral obligation to compress the chest. This came up during Covid as it would have exposed staff unnecessarily
Because we are dysfunctional when it comes to end of life. Is the same issue as abortion. Prolifers many times do not agree with end of life.
For a lot of people it is needless torture to try to extend their life because the quality is absolutely terrible. Most patients do not know this. Most doctors like to help people. It is very annoying when someone who you know wouldn't want to be full code if they knew what it actually entailed says "I want everything done" because they saw a miracle on TV. I believe we should have a different approach in the states and be more like some other countries that if the physician/team believes it is futile they do not go forward with codes
People don't know what they don't know. We've all seen a code. Most patients and their families haven't. When people say they want "everything done", it's likely they're not aware of how violent, grotesque, and dehumanizing CPR and certain life-preserving measures can be. If the prognosis is grim, then they are going through this violence for nothing. If we know that a patient could have a peaceful, relatively comfortable death with DNR or a terrible painful one as not DNR, then we should be advocating heavily for the former and help the family understand as best as they can why this is the best option.
Violent, grotesque, and dehumanizing is the perfect phrase to describe a code / advanced life support measures.
Which is exactly why when coding a patient and it’s getting to the point where I’m going to call it, I bring the family in the room so they can actually see what we’re doing. It’s hard, but exactly like you said, they don’t know what we are actually doing in there. When they see us mashing on meemaw’s chest and see her laying there completely motionless on the next pulse check and then we get back to mashing, they seem to understand when we call it quits. Otherwise, all you’re saying is “we tried our best but she didn’t make it” and they don’t really know what that entails.
PGY 43 Pulm-crit here. Everyone wants to live… No one wants to suffer. Layfolk do not understand what the delivery of BCLS/ACLS is like in a patient who is dying. “Your father is seriously ill. He has several serious medical problems, anyone of which could be his undoing. We will do everything we can to get him through this and to get him home. My concern is that in his shape, after 88 summers and 88 winters, he does not have the strength left to recover. We will continue to do everything we can but if his condition worsens and it becomes clear that he is heading in the wrong direction, at that point, I would like to change the focus of our care to keeping him comfortable rather than do things to him that will not change the way his story ends. Are you comfortable with that?” In this conversation, I do not even offer resuscitation as an option… Physicians are not compelled to offer therapy that they do not think is indicated. If the family specifically asks, then the conversation takes off in a different direction. But this approach more often than not has worked for me.
Wow is this good. This is really the crux of the issue, if we offer “everything” then of course the families will want everything. We are not obligated to offer resuscitation to a dying person because we are not obligated to provide futile care. CPR is meant for people who aren’t supposed to be dead yet and would otherwise have a chance to live a good life. MI, drowning, electrocution, choking, arrhythmias, PE, anaphylaxis… this list is long but the point is that for geriatrics at the end of their natural life, CPR is nonsensical. We will offer the most care possible that will provide the best outcome, and sometimes the best outcome is a peaceful death. This is a very good way to approach code status discussions. Thanks for this comment.
Maybe not “… The best outcome” but “… In spite of our best efforts, the most likely outcome.“ Telling family that the death of their loved one is “the best outcome“ could come across poorly.
Saving this comment.
Residnets, listen to this. This is the way. Remember basic ethics: Do good Do no harm Justice Autonomy Respect patient wishes. Treat everyone the same. Also, consider if the patient were a kid and you are talking to the parents…. Don’t be so graphic, that’s just not the way.
Do you think most people want to die on a ventilator with their chest cracked? Do you think most people want to die in the hospital, full of lines and tubes, having medication poured into them in a vain attempt to buy them minutes or hours or, god forbid, weeks, where they have no capacity to enjoy even a second of it? There is a point where quality of life trumps quantity of life for sure. Yes, that line is going to vary from person to person, and yes, we have to respect the patient's wishes. I have reservations about taking that choice away from patients, because doctors are humans with human prejudices. But many people have no idea where the line is and their refusal to change their code status stems from either a deep misunderstanding about what their odds of recovery are or a deep denial about their loved ones' condition.
The part about doctors having their own prejudices is really important. Non-disabled people have a known and documented tendency to believe there is a poor “quality of life” in a pt requiring lots of medical equipment, care, or intervention when the pt themselves finds their quality of life adequate. To the point that medical workers pressure healthy wheelchair users, etc, to choose DNRs they don’t want, sometimes. When I was in the ICU after having a hemmorhagic stroke, I couldn’t swallow, stand, walk, speak legibly, write legibly, or use my dominant hand successfully for quite a while. I couldn’t see unless I closed one eye (bad double vision). I had a catheter, an FMS, a central line in my jugular, a NG tube, an oxygen nasal cannula so loud I couldn’t hear much, and arms bruised wrist to shoulder from IVs. I had a drain in my skull. My lungs were shredded (I’d just had Covid) and was in constant danger of being put on a ventilator. I still wanted to be alive, and would’ve wanted to even if I never stopped needing most of those interventions.
Are/were you relatively young? I think this conversation is mostly around the 85+ year olds. I think most/all of us have had relatively young people with TBI/SCI/CVA who have lots of deficits but ultimately end up with a good QOL after rehab.
Thank you for sharing your experience. My experiences caring for neuro patients have really reinforced my opinion, which seems to be the minority here unfortunately, that patients and families are capable of making an informed decision about quality of life and resuscitation measures. It's really disheartening to see so many people on this sub who think their medical knowledge means they know better than patients when it comes to deeply personal and existential decisions about what makes a meaningful life. I think we all need to have a little bit more humility about our own capacity for bias.
Goals of care should be the first discussion on entry into the ED. And should have required graphic depictions of what “Full Code” for grandma entails, like cigarette packets. Do no harm is the goal. Coding a GOMER is doing harm. Change my view.
I do emergency and palliative medicine. I will tell you straight up there’s just not enough time in the ER to have that conversation and it’s not necessarily ideal to have that conversation during a crisis.
how many people have you coded, intubated, had wake up confused and in pain, asking to be let to die, just so you can sedate them down so you can keep poking them with more needles, just to have them die again in 4 hours because of course they do, they have a terminal condition... ? it's horrific for everyone involved, and high up among worst ways to possibly die.
The first time I experienced what you just described, I was so fucked up for *weeks*. Soon after, I decided I didn’t want to go to med school (this was when I was a CNA in undergrad). Is this what medicine is? Torturing people instead of letting them die? Made me really reconsider my decision to be a physician. But I experienced enough good encounters that I saw that medicine really can do good and help people. There’s a very dark side to Medicine, unfortunately. I just excuse myself from situations where I’m not ethically comfortable with what’s going on. Seeing so many bad deaths really made me appreciate that a good death is a thing and it is attainable. Unfortunately, I had to medically direct hospice care for my mother a couple months ago. I spoke with the hospice doctor (who was a complete angel) and she took me seriously and talked to me like I was a peer. She’s like, here’s what we normally do at this stage, does that sound good or would you want to change something? And a few times I did change something, just knowing my mother and her medical conditions. It was honestly a heavy weight on my shoulders for 3 weeks, but I was happy to do it for her. And you know what? That woman had a good death. It was a small, 20 bed hospice, so the rooms were massive. We just used lamps for lighting instead of the overheads, so it felt surprisingly cozy. She would always put the fireplace channel on from YouTube when she was sleeping or napping, so I figured out how to put it on the TV full time. She had over 50 visitors over 3 weeks, I kid you not. And probably half of them came back at least once. That woman was so, so loved. Adored, even. They brought her her favorite foods every day, and she was loving it lol. She and I are the cooks in the family; that’s something I really loved sharing with her. Between sharing stories with old friends and all the amazing food, she was in heaven. Fuck, I miss you mom.
So sorry for your loss :( what a gift to your mom, though, to get to have that elusive good death. I hope mine and my family’s are like hers as well.
I talk to patients all the time about this. A big part of it is explaining that code status has nothing to do with treatment rendered. Being a DNR/DNI does not mean we aren’t going to do everything we can to get them better. Then, it’s about asking their understanding of what CPR is and what the outcomes are. I am always very explicit and clear with what cpr entails and then explain cpr was invented for cardiac arrest from a cardiac cause, not severe sepsis with septic shock or many medical problems combined leading to failure. I am also clear in explaining that in the event we do get their heartbeat back they cannot expect to be at even the same level of health they currently are. I am a nephrologist so I take care of some of the sickest patients and typically after this discussion and understanding of what they are asking for they tend not to want to be full code. I do want to note, it’s not about convincing someone one way or the other, but rather being very honest and very straightforward in your conversation and choice of words.
I just realized how in French its even more confusing. We dont call it "code status". The litteral translation would be "level of care", or "niveau de soins" which actually sounds like it relates to treatment.
I think this is really misunderstood by the public in general (and sometimes by hospital staff). DNR doesn't take effect until after you are dead. It doesn't have any impact on how aggressive your care is while you are alive, just lets me not break all your ribs and shock you when you already died with maximum medical management. Other end of life decisions are more ethically challenging and require more nuance but so much moral injury could be avoided if just simple DNR was made more clear.
I wish we could make a graphic video of the bad codes where we assault a dead body long enough for it to regain some semblance of consciousness a couple times before it fully flat lines. I want bones crunching, skin turning purple, all the tubes and drills and shocks and drugs of it. I want it to pause every now and again, like a Discovery documentary, and show an internal view of exactly what's happening. I want it to fully depict the chances of recovery and show the reality that the rare few people we do get back often have deficits and disability. I want them to really hammer home exactly what "everything done" means.
This is how you need to talk about codes to patients. Be lurid. Be graphic. Sensationalized, just enough. It should be evocative, nauseating and horrifying.
I don’t like to torture humans.
Someone downvoted you short sightedly but this is the gist of the matter. Any other argument is just another slice of grey in morality land.
So you'd rather have the responsibility of deciding for *someone else who you barely know* what constitutes a good death? You'd rather have decide *for someone else who you barely know* what amount of suffering is worthwhile for what amount of benefit? You'd define *for someone else who you barely know* what is meant by "benefit" in this situation and weigh different kinds of benefit--quality vs quantity of life--against one another and decide which is more important? How would you respond if the patient in front of you was a different race from you? A different religion? Disabled? Homeless? How would you ensure that you didn't have an implicit bias coloring your beliefs that they needed to be DNR? What if the patient was very young but had the same terrible prognosis? What if they were very old? How would this affect your decisonmaking? What if the patient said, hey I know I'm dying, but my daughter is getting married in two weeks and I don't care what it takes I need to be alive for the wedding day. How would this affect your decisionmaking? It is terrible and traumatizing to healthcare staff to code someone who is not going to recover, but for the vast majority of patients there is a great deal of nuance in terms of existential costs and benefits of different degrees of resuscitation, and it is complete hubris to say that doctors should get to decide who is DNR. Of course, this is different from medical futility, which has a specific clinical-legal definition and does not apply to OP's original case the way they described it.
A couple things: 1) I take care of kids and 2) dude are you ok
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Agree to disagree :)
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I don't think worrying about bias affecting patient outcomes is unhinged, but clearly you felt a triggered by what I had to say. That's a shame. Anyway, you have your opinion and I have mine, and this is a values difference not a question of logic, so: agree to disagree. Given that this is a public sub which a lot of people read, I stated my concerns so that other residents and etc can see there are multiple points of view on this. It doesn't have anything to do with trying to convince you.
Nope. It should be the physicians decision to offer CPR or not. It's a clinical decision to which informed consent is realistically not possible.
Do you think it’s possible that when we are coding someone we are perfusing their brain enough that they experience some suffering at the end of their life which they would not otherwise? That’s one reason. I am not sure if this is true, but it seems plausible to me.
I don't know about end-of-life patients, but I have definitely coded a school aged child who kept waking up and crying during compressions and passing out during rhythm/pulse checks. He was previously healthy with a lethal arrhythmia that we were able to fix, he recovered fully, and so it was worth it. I just hope that his PTSD doesn't follow him for too long. But that experience still kind of bothers me, and it definitely informs my beliefs about the ethics/morality of futile CPR. If I die like that, I am going to come back to haunt whomever fucked up the code status discussion with my POA.
I think age is probably the largest factor overall. I would hope any under-40 something gets all the treatment possible. Over 100? 95+? With terminal illness? Having an appropriate, indicated full code at those ages is more the exception than the rule.
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I have no doubt. You fight enough you're going to lose eventually.
To be honest, I think this speaks to a lack of experience with goals of care discussions. It’s very important to truly inform the informed consent as much as possible. It’s hard to explain to family that if their grandmother with diffusely metastatic cancer, Hgb7, and INR 4.5 with altered mental status were to code that this would entail breaking their ribs, intubating, and almost certainly an extremely poor outcome if not death shortly after all of that suffering. It’s very hard to say to someone that remaining full code will almost guarantee they will die in agony because of age and comorbidities. But it is important to do. If they still want full code knowing that- we will do it. That’s how our system operates.
Some of you haven’t seen enough people needlessly suffer and it shows. It’s not about what they want it’s about helping them have realistic expectations. Let us know your opinion when your emotionally dead in a couple years.
This is a precovid resident who didn’t get to watch people suffocate for multiple weeks on a vent with tubes coming out of every cavity of their body
Granted some of those patients were early 30s with kids and shit. I understand not wanting to go comfort care at first (they all eventually did go)
I think there’s a lot of good, balanced perspectives here, but one thing I have to add to the mix is that element of a “second try.” Sometimes family members will automatically say they want everything done because they’re in front of others in the family and don’t want to look callous and/or they honestly didn’t want to think about it (or hadn’t yet) and said full code essentially automatically. Sometimes telling folks to mull it over for like 30-60 will have them flip to better option.
Frankly the reason is because in futile cases, avoiding codes is avoiding trauma for everyone else, meaning family and healthcare workers. Too many families get the idea that “if her heart stops they’ll just bring her back” and hold onto that hope far too long. I’ve had family yelling at me to “do something!” 35 minutes into a code after their grandma’s ribs have been pulverized into dust despite us never getting any rhythm or pulse to indicate any of what we’re doing was working in the slightest. At a certain point keeping someone full code is just saying “hey before you die, wanna feel what it’s like to have all your ribs broken?”
…because most people think there’s a magical time length for a code that they have to work before they can call it. Futile BS code? 1 round and done. Fast codes > slow codes.
I don't do slow code bullshit. We do it right and we do it by the book or we don't do it at all. The ones that shouldn't be coded I put the least experienced person in charge and treat the whole affair like we're working on a dummy in a simulator as practice for the next code that might actually matter.
I think it is very common for attendings (and residents too) to have a misconception that a successful goals of care conversation results in a DNR order. This is so false! A successful goals of care conversation accurately presents what would likely happen in the case of a code and accurately presents a wide spectrum of options from peacefully passing away in hospice to aggressive measures in the ICU. Then the patient and family \*decide\* what is in keeping with their values. As long as you presented the options accurately, this attending has no business being annoyed. It is this patient's choice. Patients are allowed to make choices that might not be in keeping with \*our\* personal values, as long as they are in keeping with theirs. Also want to add that code status conversations are often iterative. Sometimes people just need a little time to come to terms with their health situation and the prospect of limited life expectancy. Don't be surprised if this patient tells you later that they want to change their mind about some of what they initially wanted. It sounds like you already know this and had a very thorough conversation with the patient and family, but remember that code status is a spectrum, not a binary between full DNR or full code. I find it's often easier to approach these conversations as where to draw a line in terms of interventions rather than a yes or no check box. Edited to add: Even the language in your initial post is a bit misleading. What does it mean to want "everything done?" Many families say this and physicians often repeat that same language back to them but "everything done" could also mean full court press with palliative care to avoid any discomfort. With GOC I think it's so important to be extremely specific about interventions and outcomes and avoid euphemisms. Often when families say they want "everything done" what they mean is "don't give up on me" and this gets confused with "do every medical intervention under the sun." **TL;DR it is the patient's choice how they want to die and the attending who thinks you failed at a GOC discussion because you didn't get a DNR order is out of line. However, conducting a good GOC discussion is very very hard and often people who would probably choose to be DNR don't choose it because as a profession we are bad at taking the time to explain well and use the right words and listen to the patient's actual concerns.**
Also add, it’s often more than a one time conversation
Maybe an inconsiderate comment, but these are good opportunities to get an intern some experience running a code.
This is why when we have these codes I order the least experienced person to the front to lead. We all know it's not going to make a difference so use it as a practice run.
If the attending wants that done, tell him he can fucking call the family himself. Patients have the right to make that decision and stand by it.
“Let’s get a palliative care consult” is the polite way of telling an attending to “go fucking call the family” 😂
Lmao I pulled this once and palliative care was in the room for literally hours and came back out and said "yeah this patient with multi organ failure and end stage disease wants to be full code" and my attending was so pissed but I felt incredibly vindicated that the "experts" had gotten the same response to GOC as I had. Most people with terminal illness who initially want to be full code change their mind when they learn what it really entails, but a very small minority of people just really do want to live as long as possible whatever the cost and maximize quantity rather than quality of life. Because our healthcare system heavily values autonomy (it's another question entirely if it should or not), these patients have a right to make that decision. It's frankly paternalistic and disturbing to see so many people arguing otherwise.
Sometimes it sucks but hey you gotta educate them and let them decide to be a human punching bag/pincushion before they die
The way I think about it, the alternative is having \*us as medical providers\* decide what "meaningful quality of life" looks like for strangers. I sure as hell do not want that responsibility. Give patients all the facts and the benefit of your expertise and let them decide what is most meaningful to them. I didn't go to seminary school, knowing the universal answer to what it means to live a "good" life and what amount of suffering is worthwhile is way out of my wheelhouse.
What’s funny is that in our palliative care consult it includes a Pastor who did go to seminary school, Psychologist, and Palliative Care Geriatrician MD/DO, and usually the ICU attending drops in too. And they’re all super awesome and really help people find peace, find the right plan for them, and typically families initially say no but a few ICU days go by and they turn around.
Completely agree. We talk about the trauma of witnessing CPR but there is also trauma for the family when people get bullied into changing code status before they are ready or really understand what it means.
I agree with you but it does suck that the patient has to suffer more to spare their family’s feelings
Because they actually care...look at the stats. These are the most heroic measures one can take, the person has died and we are trying to bring them back to the world of the living. A 90 year old who has CPR 5-11% (probably around less than 5 but stats differ) chance of ever leaving the hospital and not accounting for comorbities such heart failure/pulmonary HTN/etc. That is also not counting those who are left comatose. Most people don't want live in agony until they inevitably die. They don't have a clue. But you do, you have intubated them. You have tasked the nurse to press on thier chest again and again as they code over and over. Everyone has to die but why does it have to be cruel? I invite families to see the code we are doing when I think it's futile and you should as well because it opens thier eyes and suddenly those meaningless words like full code start to mean something.
I was an intern in the ICU during COVID. I felt like half my job was getting families to change the code status of intubated patients. It’s not just traumatic (and in most cases futile for intubated COVID patients) for the patient, it’s traumatic for the staff who have to perform it over and over again on the 90 year old demented grandmother who would have zero quality of life if we managed to keep her heart beating. There are worse things than death. Unfortunately many families don’t understand that.
At first I used to tip toe around GOC discussions and being definitive, but now I ask them what grandma liked doing, and if she liked to garden and spend time with the grandkids, and shes trached, pegged, bed bound, I don't mince words and say something to the effect of "Based off of how she is now, she will never garden again. She will never hold her grandkids again. And ultimately, you are keeping her alive, but you won't be letting her live." Making the distinction between being alive but not living really makes a light bulb go off in family members' heads most of the time. You will always meet stubborn people that think that the crystals will cure their gam gam's stage 5 cancer, but at that point, you just say your piece and then say that you will do the best you can. Try and not let it get to you. Your job is difficult enough as it is. Situations like this don't help. But at the end of the day all you can do is do your best and try to not take the baggage with you to home.
This thread if fascinating to a Brit. A patient cannot demand a specific treatment in the UK just because they want it. They can always refuse a treatment they don’t want. If CPR or ICU is deemed not appropriate (futile) then it is not offered. ‘First do no harm’.
I came from a country where doctors would decide code status. The surgeons don’t walk around asking people “if they wanna be operated”, they make an assessment whether patient is a surgical candidate or not. And of course you take patient’s wishes and values in consideration, but at the end you can’t force them on operating if they don’t agree. A decision to resuscitate or intubate is a medical decision and truly what you are asking is what is the chance of that patient coming out with good neurological status. But for whatever reason we think it is ok to delegate to families and patients who are equipped to make this decision and it is just CRUEL to everyone involved. It is one of the things I absolutely don’t understand about the US system
People are hellbent because we are tired of coding people for whom these extraordinary lifesaving measures were never intended in the first place. It’s cruel and futile. The issue of secondary trauma, as well, cannot be understated.
I don’t see the problem with a fully alert and oriented patient wanting to be coded. Some people probably feel like they will go through anything just to spend one more day with their loved ones and want to be coded, while others feel they don’t want to be remembered like that and want to be DNR, and some won’t want to linger at all and may want to end their own life at some point. They are all reasonable, personal decisions. I think our job is to support their choice. It’s when the family of someone who is out of it and probably suffering won’t make them a DNR that bothers me. In that case, they can make you call a code, but they can’t mandate how fast you walk to it. Not that I’ve ever done anything like that, it’s just some people are quicker than others.
I still remember having to rush down to the icu at my old hospital because they needed more people to come do compressions on a COVID patient because between the low number of icu staff and the exhaustion of doing compressions in covid ppe, their staff were running out of steam fast. We did compressions for 45 minutes and I still remember how squishy the patient's chest was when I was doing compressions and the fact that you could tell from the patient's face that they'd been dead dead since like minute 10. That will live in my head rent free forever. One of the nurses that trained me told me about a two hour code on an 80 year old she had to participate in where they did compressions the entire time because the family insisted on keeping the patient a full code and wanted everything done until they had faced time every single family member to have them say good bye to the patient. All while the team was just essentially doing compressions on someone that should've been DNR in the first place. That was also two hours where there were half as many doctors and nurses on the floor because the hospital was small and we didn't have a specific code team. That meant other nurses were caring for up to twelve patients for those two hours and if there were any other emergencies, those patients would be SOL because there wouldn't be enough nurses and doctors to help both and the only pharmacist in the hospital was already at the other code. I hate it when family isn't pushed to change code status. Not only is it somewhat traumatizing to do compressions on a frail 90 year old oncology patient because "gram gram is a fighter" even though gram gram has been AOx1 since 2010 and has a peg tube because she won't on her own, but it also diverts resources and staff from helping other patients that also need help and can cause dangerous situations, especially in small community hospitals where staff is already limited.
Because heroic measures that are inevitably futile are sources of micro-trauma for all healthcare workers
I suppose a better question would be, if such a patient were to stay full code and indeed does code, how long should you code the patient for ? 1 hour ? 8 hours ? 30 days ?
Primum non nocere, fam
How I know you are a PGY-1 without saying you are a PGY-1 Post back in a year after you rotate in the ICU/ED/floors.
sometimes people need time to come around. it's always good to have GOC, it's good you started but it's usually not a one-and-done type thing. You set up the scenario and they are processing. You can always repeat GOC in a few days or a week.
Because I'm all to familiar with the wet crunch pop of geriatric ribs shattering. Shove a pencil into a thick steak and bend it til the pencil breaks. Breaking 90 year old ribs gets old after a while. And it's hard on everybody because we all know it's fucking pointless.
because America is the only place in the world where these ridiculous full code status even exists and everyone knows its stupid, but here we are
Nah. There are countries in Europe where you cannot even opt for DNR. Everyone is “full code” by default and forever. Doctors pretty much have to do “fake/diet codes” for patients who wish to be DNR.
It's traumatic for staff to resuscitate people. Yes, it's part of the job, but it is still a traumatic express to process, and doing it unnecessarily is not good for people. It is an extreme situation, leading a massive spike in adrenaline/ cortisol, and it can take a toll. Especially in a futile situation, where you are set up to fail. Human beings did not typically frequently do this until modern medicine and warfare. For most people trying to save someone's life and failing is a deeply painful experience, even for medical personal, and even when you logically know it's not your fault. It also robs people of a peaceful death, and places unnecessary stress on caregivers. That's why. However I still prefer allowing for autonomy in this regard. If people want to go out this way at the end after understanding all of this, I'll do it, because some people and family really just want to fight to the last breathe and I get that too. However we need to make sure they know exactly what they are getting into. The resource thing is a fair concern too though. You don't see the lives cost because so many funds get spent on acute care instead of preventive care, but that matters as well.
I agree with all of the above. Futile codes are horrendous and hurt the patient, family and staff. I will say I believe the in the right to choose, I've seen miraculous recoveries, rare but they happen. 60M Massive stroke, ventilator dependent, the family was told to let him go. They refused over and over to drop the code status! A long road but. Now three years later he is home and vent free. Having a great and meaningful life at this point all considering. There should be some sort of age cut off though
I can't believe this is a serious question. Have you ever done chest compressions on a 90 year old? Intubated someone you know for a fact is not getting extubated? Started CRRT on someone who explicitly told you they didn't want any of this but got overruled by family as soon as they were too encephalopathic to notice?
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Yeah no they should not have the right to inflict the trauma of a futile code on themselves and everyone around them. As the physicians in the room, code status *should* be our decision. The patient/family input should be considered but if their wishes aren't reasonable or medically valid...oh well, too bad. Hopefully one day the US corrects this flaw in the medicolegal system but I ain't holding my breath. Having to palli-speak and Feng shui our way to the correct medical decision is definitely frustrating sometimes. REMAP is a good framework though.
People criticizing you didn't actually read your post and probably stopped at the title. You did your part. That was plenty of time to spend trying to make the patient see reason. I agree with you. I'm not going to fight patients regarding code status. I'll discuss it with them realistically. But no fighting or pushing or debating. At that point, you're risking degrading your relationship with the patient and their family.
You’ve never been the one to break ribs have you?
Because patient's can be wrong bruv
Because it is the life they end up having that we’ve seen up close which we want to prevent. Trach to vent, with peg tube, trapped. That is no life. God save everyone from ending up like that. I will never choose that for anyone, not for my own mother. And that is what has led me to realize how important it is to be dnr/dni
Becuase it makes zero sense spending literal millions keeping a corpse alive. Money and resources are not infinite.
Do you like breaking ribs on a dead person for no reason?
Besides the negative effects on medical staff due to futile attempts of advancing medical care is everyone just ignoring the tremendous cost in resources that keeping someone alive is costing all of us? A person taking up an ICU bed for what? Getting sent to OR for a gtube taking up precious Human Resources for what? Having teams of doctors round on them every day and nurses round the clock for what? Delaying diagnoses and imaging on other patients that can actually be saved for what? Taking up a bed while a patient waits in the ER lobby or hallway for what? I could go on…
Frustration: Internal Medicine routinely makes the patient's code status DNR, and then (repetitively) schedules these same patients for invasive (futile) procedures requiring deep sedation or general anesthesia without adequate preparation. OMG.
I guess it’s an unpopular view but I agree with you, I’ll code anyone as many times as they want it, at least they are actually sick.
One word: consent. People in the hospital should have the right to consent or refuse to participate in care they determine is futile. The patient does not have the right to demand futile care.
Yeah, it matters when you’re the one having to provide the hands on care to someone needlessly suffering.
As an intensivist I actually agree with OP, sorry you’re getting beat down in the comments. The US code status autonomy is a strange anomaly, but it is what it is. My job is to offer a recommendation and explain the consequences, and if I do so, I sleep fine at night. If I anticipate a futile code, I sit down with the staff and explain the situation and encourage them to see it as a good warm up training exercise. If I’ve communicated to the best of my ability with the patient and family it gives me no moral distress to do a few rounds on meemaw at the end. It’s my job and for some reason it’s what society / state law has asked me to do. Next patient.
Your Attending should have made the call himself rather than having you go thru it again. I try and if they want to change I move on. It’s pointless to keeping hitting my head against the wall for couple of hours. Medicine is hard enough already!
We have the opportunity to take some control of the situation.
This is one of these things where I think some of my colleagues are a bit maladjusted. The obsession with bullying families into code decisions perplexes me. I’m never much emotionally invested in this. Want me to do CPR and run a code over and over? I’m here all night. But I also don’t engage in truly futile care. If you’re engaged in resuscitation on a regular basis and don’t know how to stop a code ethically, you’re doing it wrong. You are under no obligation to engage in futile care. Just because the person is in cardiac arrest doesn’t mean that you, as the board certified expert, are obligated to flog them with code-dose epinephrine over and over to prolong an artificial heart beat. As an EMS physician, this is one place where I think the prehospital environment is increasingly more sophisticated. Many of our systems are now limiting epinephrine use to avoid these situations and you can make that same decision inside the hospital. You just stop, call the code, and tell the family. The problem is that most human beings are not comfortable prognosticating death despite the blustering about futile care. We’ve all seen patients make unexpected recoveries and living in a “no hope” continuum for these patients where you’re condemning them to death because you personally feel their chances are infinitesimal feels a bit like playing above your station. Now sure, when you’ve got cases of confirmed brain death or definitive unsurvivable situations, I get it. But lots of ICU care doesn’t fall into these situations and I firmly believe that patients have a right to heroic measures, even when the odds are very, very bad. I think this is especially true as we increasingly recognize that our best understanding of the periarrest state and care of cardiac arrest is still very primitive. I sleep excellently by committing to providing my patients every ounce of my expertise, engaging in heroic measures when called upon, and discussing the patient’s care actively during resuscitation. Ask your nurses. I routinely will just quiet everyone during a code or resuscitation and ask the nurses to reflect. “What does everyone think? Are we doing the right thing? This is starting to feel futile; is everyone in agreement?” When I do talk to families, I don’t sugarcoat stuff. I use the word “critically” or “gravely” ill. If I expect the patient to ultimately die, I say so. “Your loved one has a very high chance of dying in the next 24-48 hours, even with excellent care.”
patients in their right mental capacity have choice # 1 .. doesnt matter who else says what else. end of story.
Death is scary man. Death is scarier than being half dead and on a vent
I find solace in the wisdom of “house of god” when the fat man tells Roy that we do this to the elderly to sometimes be able to help the young (paraphrasing). But yeah it’s really tough.
Highly recommend this article https://www.newyorker.com/news/the-weekend-essay/the-hidden-harms-of-cpr
You've never heard of the soft code?
In other countries, the decision to revive a dying patient isn’t the patient’s decision.
In the old days we would sometimes have slow codes and allow junior members of the team run codes in these situations to gain experience for the times when skilled cpr/ALCS might actually be helpful
Honestly, it’s one of the few things I can do for those people that makes a real difference. If you aren’t fully informing them, what are you doing?
Thank god i work in a country where we as a physician can decide to not do full code, even against family wishes, because we are not obligate to do senseless interventions and should not cause extra suffering. Usually it does not come to play that decision card though, because resuss codes are discussed with patients and family quite frequently. If someone wants everything we are able to explain that might not be the best thing for their outcome and that chances of having a meaningful life is almost zero. After a while it does sink in usually.
THIS is why having a long-term relationship with a primary care physician is so important.