Do Resuscitate Status: a Legal and Ethical Challenge for Nursing

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Do Resuscitate Status: A Legal and Ethical Challenge for Nursing

Shawn Wolkart
Senior Integrative Seminar
Spring A semester, 2010
University of Saint Mary

Abstract

A status of do resuscitate in those critically ill patients may result in a slow code. A slow code is a situation where the nursing staff decides to do less than the standard set forth by advanced life support algorithms and the nurse practice act and allow the patient to die instead of possibly sustaining life. The legal implications include falsification of documents and breaching the standard of care set forth by the nurse practice act. The ethical issues include malfeasance, dishonesty, and taking on the role of deciding who has a chance to live during a life threatening situation, demonstrating medical paternalism.

When I was in nursing school, I did my rotations in a couple of intensive care units (ICU). Often I cared for patients who were very ill and possibly dying. I took very seriously the task of discussing do not resuscitate (DNR) status with the patient and family, even as a student. Many times, death was anticipated and those involved were ready to make a decision toward do not resuscitate status. The legal and ethical dilemma arose when the patient or family was against DNR status and wanted everything done. Some of the intensive care units that I have worked in had an unwritten status of "slow code" that the nursing staff would assign to patients that, according to consensus, would not survive. This slow code meant that the staff would call the code after the patient was too far-gone for successful resuscitation or that advanced cardiac life support (ACLS) protocol drugs would not be given. It may have been less than adequate CPR or decreasing the concentration of oxygen used. I had the understanding that life saving resources was not to be wasted on these patients. I heard nurses talk about squirting the drugs into a garbage can or into the mattress of the bed. In one small hospital in a small town, I rotated through a 7-bed intensive care unit. When the manager of the unit would receive a synopsis of the patients and their statuses she would ask about code status. She would tell me that ICU did not need to waste its resources on patients with a do not resuscitate (DNR) status. I, however, believed that “no code” did not mean “no care”. This manager would push the nurses to talk to the family and physicians about making the patient a DNR so they could be moved out to another level of care. For those patients with a dismal prognosis that did not become DNR, the staff would then decide if they should be a “slow code”. As a new upcoming nurse, this appalled me. How could nurses decide when we gave our all and when we held back? I never participated in these slow codes but I never reported what I heard. At that time I was certain the manager would have supported or even taught the nursing staff the techniques of slow codes. Performing these slow codes was a breach in legal and ethical conduct. Legally, the charting would include the drugs given that were actually being wasted, constituting falsification of documents. If these nurses were turned over to the legal system, they could have been charged with harm to the patient by with holding treatment. The nurse’s participation also breached the nurse practice act by not following the standard of care. Ethically, there are issues of malfeasance, dishonesty, and "playing God" by making decisions about life and death. There were many times that I felt that our efforts were wasted on ninety year old patients with radiation markings for cancer treatment but I always tried to do my best and follow the patients and family’s wishes. I spent time explaining to families the condition of their loved one and what resuscitation did to a body. I wanted the family to understand what resuscitation efforts looked like and the damage they may cause. My...
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