Slightly Used Posts: Full Code

A repost of one my better entries, marking my first year writing here. Originally posted February 2010.

Far nearer to death than life, yet her eyes, pale blue like a set of china cups my mother once had, were suffused with light, and her eyes showed life and that was all that remained. They were mostly drowsy now and half-opened: her body was a discarded husk, wracked by strokes,  and further insulted by dementia. She recognized no one and spoke not at all. She had decubitus ulcers over each hip, deep and foul, eating into the underlying tissue; she could not lay on her back: the contractures from her strokes had pushed her frail legs up to her chest. She lay in a fetal position, at the end of life, but she had no cushion of amniotic fluid, only a thin emergency department mattress and a few pillows. She was incontinent of stool and urine, and when the ambulance off-loaded her onto the emergency stretcher, her adult brief was heavy and soaked.  The stench of piss, strong and rank with (I suspected) white cells and bacteria, was overwhelming.

She could not swallow, and this, perhaps, was the ultimate source of her problems. She had a feeding tube inserted directly into her stomach, through which she was nourished by a sophisticated version of Ensure. Patients with feeding tubes are supposed to be propped upright after feeding to avoid any regurgitation of the feed up the esophagus and into the lungs. At some point or place, this was not done; maybe her contractures made it difficult to position her, or maybe she vomited anyway. At any rate, she aspirated, and a good deal of her stomach contents passed into her lungs, in turn prompting a pneumonia.

In short: she was demented, stroked, hopelessly contracted, ulcerated (and along with any number of nontrivial comorbidities, like coronary artery disease and diabetes) — a patient with objectively no quality of life from a nursing home notorious for providing poor patient care. She was febrile, hypotensive, dehydrated and probably septic. And after 89 years, 6 months, and twelve days and maybe 3 1/2 billion heart beats, she was dying at last.

According to the nursing home notes sent with her, she was a full code.

Full code means, if a patient has a cardiac or respiratory arrest, we are ethically and legally obliged to perform life-saving measures. We go full tilt. Rib cracking compressions, intubation, defibrillation, various push medications and infusions to prolong life, in this case, for a few hours or days.

We cleaned her up and assessed her, started an IV and the antibiotics, and after a while, her daughter arrived looking older, I thought, than the date that would show on her birth certificate. She sat by her mother, and even so, she looked lonely, worried, unhappy. She stroked her mother’s hair, all the time looking for those eyes, now closed.

I asked her about her mothers wishes, and what would she would want if she knew she was dying. I asked her about what she understood about resuscitation, and discussed with her all the treatment options. Finally, I asked what she wanted us to do in case her mother’s heart stopped.

She seemed puzzled by the question. She considered, and then said with unintentional humour, “Maybe a little shock or two to help her.”

I suppressed a smile, tried another tack. I asked her about her mother’s life. Silence for a moment, then she told me about her mother, who did “nothing important” but carried the burden of a drunken, abusive husband for forty-five years, until he mercifully died in 1988; after which her mother seemed to bloom for a season of five or six years, until the first stroke, and then a second left her nearly completely debilitated.

Was there conciousness at all behind those blue eyes? I wondered. What would she want?

I went through all the treatment options again, while she held her mother’s hand. I talked about quality of life, and futility and dignity.

“She wasn’t important,” the daughter repeated. “She never did anything exciting. I’m all that’s left of her.”  She peered anxiously at her mother’s face. She would not make eye contact with me. “She has me and I have her.”

I got it, at last: she wasn’t ready to have the conversation.

I thanked her for her time and assured her her wishes would be respected.

I thought: full code granted her mother importance, as if we  in attending to her death we would give life significance. Full code meant her life had value and meaning, after a life of seeming meaninglessness. And at the end, all they both had left was each other.

I flipped through the chart to the nursing notes, and set pen to paper. I started to write: “Full code. . .”

  1. #1 by Jenn Jilks on Sunday 05 September 2010 - 2029

    Sad story, even a year later. I told my daughter to shoot me, in this condition.

  2. #2 by Donald Wood on Sunday 05 September 2010 - 2051

    Spoken from the heart as only one who has been there can do. I am always amazed by the pronouncements of politicians and philosophers on how to handle these situations. It is easy to make statements in the clean cut, non-clinical world that is removed from the close physical presence of the parties involved. My wife and I (both nurses) have been there with family members. It is tough when everyone else looks at you when the question of the code status comes up. No matter what your answer, it is an gut wrenching, emotional time to make the words come out of your mouth. Luckily the other family members all agreed with our decisions. (We lived next door to her parents for 23 years. We had sought out their wishes well in advance.)

    For those with parents who are aging (even if they aren’t old), have these conversations now. It could make the future a tiny bit easier for you. Only a tiny bit but at that point, every little bit helps.

  3. #3 by The Nerdy Nurse on Monday 06 September 2010 - 1624

    There is no right answer to these sort of questions.

    It is so important that you inform your love ones and put into writing what you wants and needs are for your medical care

    It is not our place to decide what is right for each patient or their families. It is our place to inform them of the options, goals, and care we can and will provide. You get that.
    As much as it may pain us to initiate a code on what is a hopeless cause, I believe you are right when you said that the daughter needed it.

    We all have our reasons for doing things that others find to be irrational.

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  5. #5 by Keesha on Sunday 10 November 2013 - 2001

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