Medicine: Code or No Code?

March 23, 2011

As a nurse in primary geriatric care, you see a lot of death. Not everyone entering a nursing home expects to die there. Some come for extended surgical care, sometimes followed up with physical therapy, then they go home. However many are those who, in the progression of life, have reached the point where a lot of care is needed and is unlikely to recover to the point of being able to live independently again.
Upon entering a long-term care facility (LTC), it is required that a decision be made as to how much and how far life saving efforts are to be made in the event that the heart stops or an illness develops that look to be fatal. There are several scenarios and levels at which a different level of care can be chosen. For example, the patient or his representative can mark yes to antibiotics, but no to CPR if heart stoppage is imminent. The gray area that would require a representative to make a decision is if an illness, such as pneumonia, strikes at the patient’s weakest and an antibiotic might save them or you can let nature take it’s course. Death comes from many causes, usually at the patient’s weakest. It might be infection. It may be the gut shutting down, making eating and drinking difficult and frequently the patient refuses to eat or drink. One can force-feed such a person, but there are issues of patient’s right to refuse food. Also, if there is abdominal discomfort, it could be considered cruel to force food in such a situation. In many cases, food refusal is a signal of early descent in the process of death. “Gracie” was 90-year-old woman, wheel chair bound with complete dementia. Gradually she ate less and less, drooling the food out. Concerned with her loss of weight and dehydration, Gracie was sent to the hospital where she was burnished with IV fluids with glucose to up her energy level. However, Gracie didn’t eat or drink any better when she came back. She had just decided it was her time at a basic level. It wasn’t long before she passed on.
On rare occasions, there will be a person designated a full code. “Henry” was one such; a contradiction in character, he attempted suicide regularly while fearing natural death. Most, however, are designated full code by a family member who can’t bear to think of Mom dying or perhaps from some level of guilt.
Family member reactions vary widely. One never knows what seethes under the sympathetic face of a loving wife or child. My most memorable patient death was a genial old gentleman named “Steven”. He always had a smile as he tootled around the facility in his electric wheelchair. He had a faithful wife, “Sylvia”, who volunteered at the home and sat with him at most meals. Most everyone thought they were a loving couple.
Then came the day when he collapsed as he was being put to bed for a nap. He was a heavy guy and with difficulty the aids got him on his bed and summoned me. I always bring my stethoscope when being told someone was fading or gasping. I first noticed a definite line between gray and his normal color and it was sinking fast. There was no heartbeat though there was raspy breathing. I told the aid to start chest compressions and went to check on his code status. ….. There was none in the chart!! Sylvia had not returned them and no one had noticed. She had gone home to rest, so I called and asked if she wanted a pull out the stops life saving, CPR, heart shocks etc. After recovering her breath, she said absolutely not. No. “Don’t you dare send him to the hospital, I’ll make you pay the bill if you do.”
It was stunning. Everyone had thought they were a loving couple. Not that he likely could have been saved. The heart attack had been massive. But that wasn’t all. Sylvia stated there would be no funeral. She was going to have him cremated and dump his ashes in the garden. Her tone of voice suggested it was going to be the garbage can.
What could have happened in their lives to lead to this? Some men mellow, as they get older. Some are different with their wives and kids than they are with other people. Steven had been a popular patient and I was in deep doo-doo for “letting” him die. It was impossible to convince some people that you have to do as the next of kin wanted, even if they were convinced he’d have wanted a full code. Even if he’d had a signed paper demanding extreme life saving methods, his wife had the right to reverse it. However I had no way of knowing any of it and had to do as Sylvia asked. Maybe he’d marked full code on the papers and she deliberately held onto them until it was too late. Who knows?
I was fired shortly after and I believe that it was because of this. The supervisor responsible for terminating me was one who held Steven’s death against me. In many ways, LTC residents and staff become close and it becomes part of politics.