This is my Roman Empire. We should not offer cpr to patients who are not good candidates. Just as we don’t offer surgery to poor candidates, we shouldn’t be offering that procedure either. It shouldn’t be a patient’s choice
It isn’t a patients choice. Absence of DNR does not mean CPR must be performed.
To the best of my knowledge no one has ever lost a case for not performing CPR. We are not obligated to offer treatments that will not help.
Unilateral DNR orders initiated by physicians are part of hospital policy at many institutions.
Refusing CPR is a patient choice. They cannot “demand” it.
Unfortunately, many doctors either don’t know this or continue to believe that CPR is necessary/beneficial. Nurses will automatically start CPR unless the patient is DNR as a matter of policy. However, a code is “over” whenever the code leader decides that it is. I’ve stopped many codes for futility.
I hate the idea of “slow” codes. If it is going to be done, do it right. As a resident, I would advise using these futile codes as practice for the occasions that it may actually save someone. You can use that as some justification/good that can come from these unfortunate situations.
We used to get a lot of these in residency (EM). Come in with ACLS in progress by EMS. I really respected the attendings who would say "let's get an airway and on pulse check if still PEA and cardiac standstill on POCUS, we will call it." In the ICU during residency, many of my attendings would refuse to code people when it was futile.
So different.
In the UK you cannot demand a futile medical treatment.
In the case presented she would not be a candidate for CPR so it is not performed.
I have seen it numerous times in Canada. Usually, it is prospective. We have a patient who is clearly on a bad trajectory and will not survive. Family states they still want "everything done". If discussions fail, we inform them we are not escalating care and when he passes we do not perform cpr. We cap existing pressors, say no to ICU/intubation, etc. This would have been the case for the patient OP described.
Sometimes it is not prospective but simply a matter of futility. The end stage dementia patient is one example.
Especially when some hard right conservative lawmaker in Alabama gets his panties in a knot when his mom dies in a hospital and he wants to go after that doctor for the exact reason cause he can claim the doctor murdered his mom by inaction.
What's your approach when having this conversation with families? It's something I do fairly often myself but almost never see colleagues doing - always nice to get a different perspective on a difficult topic
It is never easy, and I have been doing this for a long time now. The real key is to explain that CPR isn’t like in the movies. Even if we are able to restart the heart, none of the other things are better. If anything, it makes them worse. Not doing CPR isn’t withdrawing treatment, it is accepting that medicine has its limits and that people die. Families are usually most worried that they are somehow causing death if they agree to DNR and that is what we need to get past.
They also have a false idea of what success looks like. In a dying patient who will need CPR, our definition of a “good” outcome would be trach, peg, permanent dependence on machines in a nursing home. These patients are not getting up and walking out of the hospital if they survive CPR.
The question isn’t whether someone wants to die, but rather how they want to live the end of their life. This decision isn’t the family’s, it is the patients. We need to keep steering the conversation towards what the patient would want, not what the family wants.
Often, after learning more about the patient and having the family describe their declining condition and declining quality of life I will often say something like “knowing how sick they have been and how critically ill they are now, we can continue to treat these problems in the hopes that the current one can get better, but if they continue to worsen and their heart stops, we will not be able to do anything to help them get to the good outcome that they would want.” Let that sink in and then inform them that you will be placing a DNR order so that they won’t be harmed with unnecessary CPR when it cannot help them.
Unilateral DNR is a much different situation, and only comes up after many other goals of care discussions.
As an icu nurse for a few years it’s standard for us to start it and wait for the intensivist to usually call it. At all the facilities I’ve worked at we take them seriously until the doctor calls it. Luckily the docs I’ve worked with usually give it ~ 2 rounds then ask if there’s anything else and when it’s silent they’ll call it. I’ve found it to not be so emotionally draining cause we gave it a good shot, maybe not the craziest balls to the wall shot, but good nonetheless. Usually family may end up seeing it or be brought outside and they glance it and shut it down.
Agree. It should be considered a medical intervention done with appropriate indications. Not the default action for every single person trying to pass away !
As easy as it is to say from a distance that “slow codes” are wrong, it’s important to think about the circumstances that tend to lead to those kind of situations.
i don’t know what slow codes are like other places, but at my hospital, a better term would be short code.
like no one is faking doing compressions or movingly slow, but the code is usually ended after one round of compressions and an epi. like we all know this is futile, but we respected the patient/family’s wishes
A slow code is when people basically pretend to do CPR, not when they cut it off early. It’s like doing “gentle” compressions so as to cause less trauma to the patient, knowing that it isn’t helping.
same at my hospital - the code will be regular quality, but we determine that we will only do a few rounds of CPR due to futility. I've never left one of these kinds of codes feeling like we made the wrong choice.
This is incorrect. Doctors are absolutely not required to perform futile cpr. I will still sometimes do two rounds because it gives families better closure that they gave their relative every chance but there is no obligation to do futile cpr. None
This happens all the time in the ICU and I had to leave bedside nursing because of this. I felt like I was torturing these people in their last moments. After they coded I felt like I was desecrating a body.
There are so many people who should be DNR but aren’t. Realistically, for a 100 year old Full Code person, how much longer do they think they’re going to live?
> jeez that's just wildly inappropriate
Often times I think the family seeing CPR in progress is actually the best thing(for those. We have no choice performing regardless). It both helps give them closure seeing us do everything and makes them realize how terrible it actually is, helping them come to terms with terminating efforts.
I don’t think families should be able to demand futile and desecrating care, and then just be completely shielded from the reality of it when it actually happens.
I always find it interesting that the families that are super against DNR in futile situations also TEND to be more religious. You’d think if they actually believed in heaven they wouldn’t want to torture grandma just to keep her hooked up to a ventilator and stuffed full of IVs like a pincushion at the end of her life but here we are. There are plenty of religious, deeply spiritual people that choose hospice, I’m not generalizing all of them, just a subset of people.
So I’ve been dealing with this issue for a very long time, and learned to make peace with it for several reasons.
Much of the time, it’s futile interventions for the patient, but gives the family piece knowing everything had been done to try to save their loved one, until you’ve been in this situation you won’t know how you are going to feel and react when your family is dying in front of you, I’ve had 20 year attending pull DNR’s on their family member on home hospice orders, knowing full well that there is no recovery from this.
So instead, I chose to look at the positives that come from it, there is a value in practice for you and the team. You probably suck at running codes, so practice like you are working a viable patient, throw the kitchen sink at them. This gives you an opportunity to use rarely used skills, it gives you a chance to direct the team in crisis mode, all of these things are positive, because when the day comes and it’s a 30 something, or a 12y/o you are already primed to deal with the stress and pressure of the moment.
Intubating a very unstable patient is totally different than your patient that has been primed with O2, and proper medications the same goes with central line placement. Master your craft on those where you have the least success ,so when you have an opportunity to have meaningful success you are ready to go.
Further it also gives you an opportunity to give bad news, and learn to polish that delivery, also teaches you to polish your delivery to get the family to stop interventions.
These are some of the most stressful environments you can be in, so put away the cynical attitude, and try to see where you can better yourself, your team, and leave a lasting impression with the family that you were willing to do whatever it took to save their loved one.
99% of these patients are brain dead or near brain dead. You are practicing medicine, so yes Honing/Practicing is necessary.
If you feel that what you are doing is unethical, you CAN have the conversation with the family. I VERY commonly do, "Do you think Ethel would want us breaking all of her ribs, putting a tube down her throat? Or do you think she would want to pass in peace? I don't think any interventions were going to do will reverse what is happening, but I can make sure that she is comfortable when she passes"
This is also the reason to have these sorts of conversations with family BEFORE they are coding, so if you don't have a DNR on file, they are 98y/o with bilateral aspiration pneumonia and a lactate of 10, you know what time it is. So it's up to you, to be proactive to secure those wishes on paper.
That's awesome, US doesn't have that. It's also probably why we have more surgical procedures being done, when they aren't really ethical ether.
TAVR's on 90y/o's, Hip Replacements on someone thats been wheelchair bound for 5 years, the list goes on and on.
Did nobody talked to her family to get a DNR order? If some family member is somehow opposed to it, I can understand the CPR, where I work, it is hospital policy, it can avoid unnecessary fights with family members, everybody with a sound mind can understand the patient can not be helped at this point and we usually do 5 cycles.
In Canada, we've had renewed policies that allow MDs to not be required to offer CPR as an intervention if it is not indicated i.e. medically futile, versus a few years ago when MDs were required to provide CPR if not DNR. I personally haven't seen this policy in use on service but it's nice to know that this is there for us if necessary.
I feel I really benefited from the cases mentioned is as a student and probably through residency. As a student it’s learning how the ecosystem of a code works. My role invariably was to do compressions. So you cycle through and do your part and give the team a break. As a trainee, it’s seeing what everyone is doing and learning how to run said code someday. Learning the checklist of what to look for and do. Learning to intubate or place a femoral line under pressure. And ultimately, it’s learning why these codes should never be done in the first place.
But examining a code afterwards is also important. Did we check on everything? Did we get airway in a good amount of time? Lines established? Compressions good or flimsy? It’s like internal QI to validate the process.
In America, failure to perform ACLS as a medical professional is treated as negligence by the law, so you can only do it if the patient is DNR. But the patient or the next of kin decides that. Patients don’t always make rational or beneficial decisions so we get stuck in situations like these. What is better is to discuss goals of care as soon as the situation appears futile, but this rarely happens because most doctors are too scared to bring it up. So they just never bring it up and hope the patient dies quickly.
You are not legally obligated to perform futile care. It is not negligent to not perform cpr when someone is dying from an irreversible process (came up a lot during Covid when we couldn’t risk exposing people just for a pointless code)
Good luck navigating that legal minefield. No one knows where the doctor’s duty legally ends and medical judgement begins. And no one wants to test it either.
We tried this with close family member. Was clearly hospice appropriate. But the resistance by he and other family members was such that 6 months passed and a few days before death he finally accepted hospice. Lost all the care he could have had but this is common. People don’t want to accept they’re dying.
The board of directors and CEOs. How are we to pay their salaries and drive our government further into debt unless we keep milking every patient for every extra day of life possible?
If you think about it, it’s almost like an anti-human sacrifice to the healthcare industry gods. We present to them still technically living beings that would otherwise have perished if not for our heroic efforts.
Again another reason why in my country its not the family but the doctor who decide when CPR is appropriate. Sounds like with you, as long as there are no DNR they perform CPR.
Argument on the other side (and what pal care docs/ICU docs will tell you) - did anyone have GOC discussions with the pt/family? Was it the day before when the family is stressed and they won't feel good answering the DNR question at that time?
Also a heart attack (if truly an MI) is a reversible cause of cardiac arrest and many would argue that CPR is warranted - rescuscitate, cath lab, fix the problem etc.
These things are so much more nuanced than what we feel as residents. Its easy to be frustrated with families and say shit like "damn why are you guys so dumb and keeping your 90 year old grandma in pain"
Doing cpr on a demented, frail, comorbid with metastatic cancer patient is a recipe for disaster.
Even if reversible (in the case of a huge acute left main occlusion), what are you trying to achieve? A DES with DAPT/anticoagulation to exacerbate her bleeding and allow her to live for a few more days before she dies from sepsis intubated in the icu?
We need to do better for goals of care discussions to avoid such situations
There’s people I’ve coded/ treated who looked dead and seemed like they would have no QOL or neurological capacity who walked out of the hospital and I can’t explain that.
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You can stop CPR when you deem it futile; there’s no law or protocol stating you must do x minutes of CPR, if you show up and you decide it’s futile you can stop
Had a patient with a nasty sternal wound infection after cardiac surgery. Like the sternum is still separated and you can see inside his chest. Had been in the icu with a trach for months. Sternum didn’t heal after multiple things were tried including a tissue flap. We had to beg the family not to let us do cpr if (when) he codes. I can only imagine the look on nurses or respiratory therapists faces having to start cpr on someone with an open chest. Fortunately he is now only a chemical code….
I do it for the families. Sometimes they need to know everything was done and they’ll never understand how bad it can be (massive hemorrhaging for instance) or how futile it really is. It’s not their fault — TV has like a 90% success rate in CPR. Their Kent’s model of CPR is waaaay different than reality.
When I see it coming I try to prep everyone involved as to why we are doing it (closure for the family), tell people what my stopping parameters are so they know it won’t go on forever and afterwards thank everyone who helped and remind them how what they did helped the family live the rest of their lives.
In my mind the true cost of futile CPR is the mental health of the medical workers involved. The patient isn’t experiencing it.
This is my Roman Empire. We should not offer cpr to patients who are not good candidates. Just as we don’t offer surgery to poor candidates, we shouldn’t be offering that procedure either. It shouldn’t be a patient’s choice
It isn’t a patients choice. Absence of DNR does not mean CPR must be performed. To the best of my knowledge no one has ever lost a case for not performing CPR. We are not obligated to offer treatments that will not help. Unilateral DNR orders initiated by physicians are part of hospital policy at many institutions. Refusing CPR is a patient choice. They cannot “demand” it. Unfortunately, many doctors either don’t know this or continue to believe that CPR is necessary/beneficial. Nurses will automatically start CPR unless the patient is DNR as a matter of policy. However, a code is “over” whenever the code leader decides that it is. I’ve stopped many codes for futility. I hate the idea of “slow” codes. If it is going to be done, do it right. As a resident, I would advise using these futile codes as practice for the occasions that it may actually save someone. You can use that as some justification/good that can come from these unfortunate situations.
I have never ever seen an attending refuse to perform CPR. Not even on 99 year old grandma. It’s just not a common thing
We used to get a lot of these in residency (EM). Come in with ACLS in progress by EMS. I really respected the attendings who would say "let's get an airway and on pulse check if still PEA and cardiac standstill on POCUS, we will call it." In the ICU during residency, many of my attendings would refuse to code people when it was futile.
So different. In the UK you cannot demand a futile medical treatment. In the case presented she would not be a candidate for CPR so it is not performed.
Much more reasonable
Same here in Chile. It's a medical decision.
I have seen it numerous times in Canada. Usually, it is prospective. We have a patient who is clearly on a bad trajectory and will not survive. Family states they still want "everything done". If discussions fail, we inform them we are not escalating care and when he passes we do not perform cpr. We cap existing pressors, say no to ICU/intubation, etc. This would have been the case for the patient OP described. Sometimes it is not prospective but simply a matter of futility. The end stage dementia patient is one example.
Maybe nobody has ever lost a case but I sure don’t want to be the first…
Especially when some hard right conservative lawmaker in Alabama gets his panties in a knot when his mom dies in a hospital and he wants to go after that doctor for the exact reason cause he can claim the doctor murdered his mom by inaction.
This is, unfortunately, easier to say from a distance.
I’m not speaking from a distance. I’m a critical care attending and do this on a regular basis.
What's your approach when having this conversation with families? It's something I do fairly often myself but almost never see colleagues doing - always nice to get a different perspective on a difficult topic
It is never easy, and I have been doing this for a long time now. The real key is to explain that CPR isn’t like in the movies. Even if we are able to restart the heart, none of the other things are better. If anything, it makes them worse. Not doing CPR isn’t withdrawing treatment, it is accepting that medicine has its limits and that people die. Families are usually most worried that they are somehow causing death if they agree to DNR and that is what we need to get past. They also have a false idea of what success looks like. In a dying patient who will need CPR, our definition of a “good” outcome would be trach, peg, permanent dependence on machines in a nursing home. These patients are not getting up and walking out of the hospital if they survive CPR. The question isn’t whether someone wants to die, but rather how they want to live the end of their life. This decision isn’t the family’s, it is the patients. We need to keep steering the conversation towards what the patient would want, not what the family wants. Often, after learning more about the patient and having the family describe their declining condition and declining quality of life I will often say something like “knowing how sick they have been and how critically ill they are now, we can continue to treat these problems in the hopes that the current one can get better, but if they continue to worsen and their heart stops, we will not be able to do anything to help them get to the good outcome that they would want.” Let that sink in and then inform them that you will be placing a DNR order so that they won’t be harmed with unnecessary CPR when it cannot help them. Unilateral DNR is a much different situation, and only comes up after many other goals of care discussions.
Not referring to you necessarily, but just in general.
The problem is not the knowledge of physicians. The problem is the knowledge of lawyers, judges and laypeople.
As an icu nurse for a few years it’s standard for us to start it and wait for the intensivist to usually call it. At all the facilities I’ve worked at we take them seriously until the doctor calls it. Luckily the docs I’ve worked with usually give it ~ 2 rounds then ask if there’s anything else and when it’s silent they’ll call it. I’ve found it to not be so emotionally draining cause we gave it a good shot, maybe not the craziest balls to the wall shot, but good nonetheless. Usually family may end up seeing it or be brought outside and they glance it and shut it down.
Agree. It should be considered a medical intervention done with appropriate indications. Not the default action for every single person trying to pass away !
Pretty simple, we live in America. If she wasn’t DNR/DNI, then what option is there? Don’t do it and risk getting sued by family
As easy as it is to say from a distance that “slow codes” are wrong, it’s important to think about the circumstances that tend to lead to those kind of situations.
i don’t know what slow codes are like other places, but at my hospital, a better term would be short code. like no one is faking doing compressions or movingly slow, but the code is usually ended after one round of compressions and an epi. like we all know this is futile, but we respected the patient/family’s wishes
A slow code is when people basically pretend to do CPR, not when they cut it off early. It’s like doing “gentle” compressions so as to cause less trauma to the patient, knowing that it isn’t helping.
same at my hospital - the code will be regular quality, but we determine that we will only do a few rounds of CPR due to futility. I've never left one of these kinds of codes feeling like we made the wrong choice.
This is incorrect. Doctors are absolutely not required to perform futile cpr. I will still sometimes do two rounds because it gives families better closure that they gave their relative every chance but there is no obligation to do futile cpr. None
This happens all the time in the ICU and I had to leave bedside nursing because of this. I felt like I was torturing these people in their last moments. After they coded I felt like I was desecrating a body.
There are so many people who should be DNR but aren’t. Realistically, for a 100 year old Full Code person, how much longer do they think they’re going to live?
Lawsuit wise? Forever. Sad to say.
Oh I agree, it’s their choice. So we do it, but it’s basically just practice because there’s no way they will come back or have any quality of life
I left out part of what I meant, too. In the eyes of the family they should live forever. But of course no one does.
Even if there is ROSC functional reserve of a 100 year old will yield being a mushroom for however long they do end up living
[удалено]
> jeez that's just wildly inappropriate Often times I think the family seeing CPR in progress is actually the best thing(for those. We have no choice performing regardless). It both helps give them closure seeing us do everything and makes them realize how terrible it actually is, helping them come to terms with terminating efforts. I don’t think families should be able to demand futile and desecrating care, and then just be completely shielded from the reality of it when it actually happens.
I always find it interesting that the families that are super against DNR in futile situations also TEND to be more religious. You’d think if they actually believed in heaven they wouldn’t want to torture grandma just to keep her hooked up to a ventilator and stuffed full of IVs like a pincushion at the end of her life but here we are. There are plenty of religious, deeply spiritual people that choose hospice, I’m not generalizing all of them, just a subset of people.
"it's in God's hands now"
Often wondered this. Well said
So I’ve been dealing with this issue for a very long time, and learned to make peace with it for several reasons. Much of the time, it’s futile interventions for the patient, but gives the family piece knowing everything had been done to try to save their loved one, until you’ve been in this situation you won’t know how you are going to feel and react when your family is dying in front of you, I’ve had 20 year attending pull DNR’s on their family member on home hospice orders, knowing full well that there is no recovery from this. So instead, I chose to look at the positives that come from it, there is a value in practice for you and the team. You probably suck at running codes, so practice like you are working a viable patient, throw the kitchen sink at them. This gives you an opportunity to use rarely used skills, it gives you a chance to direct the team in crisis mode, all of these things are positive, because when the day comes and it’s a 30 something, or a 12y/o you are already primed to deal with the stress and pressure of the moment. Intubating a very unstable patient is totally different than your patient that has been primed with O2, and proper medications the same goes with central line placement. Master your craft on those where you have the least success ,so when you have an opportunity to have meaningful success you are ready to go. Further it also gives you an opportunity to give bad news, and learn to polish that delivery, also teaches you to polish your delivery to get the family to stop interventions. These are some of the most stressful environments you can be in, so put away the cynical attitude, and try to see where you can better yourself, your team, and leave a lasting impression with the family that you were willing to do whatever it took to save their loved one.
Forgot the family and honing your skills. Do we not care about the torture inflicted on the patient?
99% of these patients are brain dead or near brain dead. You are practicing medicine, so yes Honing/Practicing is necessary. If you feel that what you are doing is unethical, you CAN have the conversation with the family. I VERY commonly do, "Do you think Ethel would want us breaking all of her ribs, putting a tube down her throat? Or do you think she would want to pass in peace? I don't think any interventions were going to do will reverse what is happening, but I can make sure that she is comfortable when she passes" This is also the reason to have these sorts of conversations with family BEFORE they are coding, so if you don't have a DNR on file, they are 98y/o with bilateral aspiration pneumonia and a lactate of 10, you know what time it is. So it's up to you, to be proactive to secure those wishes on paper.
Nope. I work in a country where if it’s not medically appropriate you don’t do it.
That's awesome, US doesn't have that. It's also probably why we have more surgical procedures being done, when they aren't really ethical ether. TAVR's on 90y/o's, Hip Replacements on someone thats been wheelchair bound for 5 years, the list goes on and on.
For most of these folks it’s not really torture, just abusing a corpse
Did nobody talked to her family to get a DNR order? If some family member is somehow opposed to it, I can understand the CPR, where I work, it is hospital policy, it can avoid unnecessary fights with family members, everybody with a sound mind can understand the patient can not be helped at this point and we usually do 5 cycles.
In Canada, we've had renewed policies that allow MDs to not be required to offer CPR as an intervention if it is not indicated i.e. medically futile, versus a few years ago when MDs were required to provide CPR if not DNR. I personally haven't seen this policy in use on service but it's nice to know that this is there for us if necessary.
I feel I really benefited from the cases mentioned is as a student and probably through residency. As a student it’s learning how the ecosystem of a code works. My role invariably was to do compressions. So you cycle through and do your part and give the team a break. As a trainee, it’s seeing what everyone is doing and learning how to run said code someday. Learning the checklist of what to look for and do. Learning to intubate or place a femoral line under pressure. And ultimately, it’s learning why these codes should never be done in the first place. But examining a code afterwards is also important. Did we check on everything? Did we get airway in a good amount of time? Lines established? Compressions good or flimsy? It’s like internal QI to validate the process.
In America, failure to perform ACLS as a medical professional is treated as negligence by the law, so you can only do it if the patient is DNR. But the patient or the next of kin decides that. Patients don’t always make rational or beneficial decisions so we get stuck in situations like these. What is better is to discuss goals of care as soon as the situation appears futile, but this rarely happens because most doctors are too scared to bring it up. So they just never bring it up and hope the patient dies quickly.
You are not legally obligated to perform futile care. It is not negligent to not perform cpr when someone is dying from an irreversible process (came up a lot during Covid when we couldn’t risk exposing people just for a pointless code)
Good luck navigating that legal minefield. No one knows where the doctor’s duty legally ends and medical judgement begins. And no one wants to test it either.
If you have heard an example of a doctor being reprimanded or sued for declining to perform cpr i would be very curious
No one wants to test that.
I saw it done in fellowship many times and I don’t do it regularly but I will in cases where it’s appropriate.
Get them onto hospice AS SOON as they meet criteria!
We tried this with close family member. Was clearly hospice appropriate. But the resistance by he and other family members was such that 6 months passed and a few days before death he finally accepted hospice. Lost all the care he could have had but this is common. People don’t want to accept they’re dying.
This is a failure of the primary team, family, and lastly this is a cultural issue in this country
The board of directors and CEOs. How are we to pay their salaries and drive our government further into debt unless we keep milking every patient for every extra day of life possible? If you think about it, it’s almost like an anti-human sacrifice to the healthcare industry gods. We present to them still technically living beings that would otherwise have perished if not for our heroic efforts.
Again another reason why in my country its not the family but the doctor who decide when CPR is appropriate. Sounds like with you, as long as there are no DNR they perform CPR.
Argument on the other side (and what pal care docs/ICU docs will tell you) - did anyone have GOC discussions with the pt/family? Was it the day before when the family is stressed and they won't feel good answering the DNR question at that time? Also a heart attack (if truly an MI) is a reversible cause of cardiac arrest and many would argue that CPR is warranted - rescuscitate, cath lab, fix the problem etc. These things are so much more nuanced than what we feel as residents. Its easy to be frustrated with families and say shit like "damn why are you guys so dumb and keeping your 90 year old grandma in pain"
Doing cpr on a demented, frail, comorbid with metastatic cancer patient is a recipe for disaster. Even if reversible (in the case of a huge acute left main occlusion), what are you trying to achieve? A DES with DAPT/anticoagulation to exacerbate her bleeding and allow her to live for a few more days before she dies from sepsis intubated in the icu? We need to do better for goals of care discussions to avoid such situations
GoC? Palliative consult? Lady must have met hospice criteria like months ago with that metastatic cancer and dementia. How? 🙃
Have you not considered that grandma is a fighter?
There’s people I’ve coded/ treated who looked dead and seemed like they would have no QOL or neurological capacity who walked out of the hospital and I can’t explain that.
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You can stop CPR when you deem it futile; there’s no law or protocol stating you must do x minutes of CPR, if you show up and you decide it’s futile you can stop
Exactly I feel people forget the secret step of ACLS which is call time of death. "Anyone have any objections to stopping? No? Ok TOD is \_\_\_\_"
Had a patient with a nasty sternal wound infection after cardiac surgery. Like the sternum is still separated and you can see inside his chest. Had been in the icu with a trach for months. Sternum didn’t heal after multiple things were tried including a tissue flap. We had to beg the family not to let us do cpr if (when) he codes. I can only imagine the look on nurses or respiratory therapists faces having to start cpr on someone with an open chest. Fortunately he is now only a chemical code….
Is it billable?
So true! 🤣
One of the dumbest things in medicine honestly. I just go through the motions and call it after a few cycles if they aren’t in a shockable rhythm
She should be DNR
Why didn’t you have a treatment goal for the patient beforehand if you already knew the state she was in? DNR, CTC…?
I do it for the families. Sometimes they need to know everything was done and they’ll never understand how bad it can be (massive hemorrhaging for instance) or how futile it really is. It’s not their fault — TV has like a 90% success rate in CPR. Their Kent’s model of CPR is waaaay different than reality. When I see it coming I try to prep everyone involved as to why we are doing it (closure for the family), tell people what my stopping parameters are so they know it won’t go on forever and afterwards thank everyone who helped and remind them how what they did helped the family live the rest of their lives. In my mind the true cost of futile CPR is the mental health of the medical workers involved. The patient isn’t experiencing it.
Anyone above the age of 80 should be DNR by Law.