When words of Code Blue are announced through overhead speakers, my heart always skips a beat, and I will start my personal struggle again among professional, legal and ethic obligation: "did I take the right action on a right patient and did I do a right thing?"
Code blue means a patient, who is in "Full Code" status, is suffering a event of cardio-respiratory arrest, and immediately needs a starting of full advanced cardiac life support protocol, including cardiopulmonary resuscitation (CPR), medication, and mechanical ventilation (Lewis, Heitkemper & Dirksen, 2006, p.166). I have been working in an adult inpatient medicine unit for six years. I can not exactly remember how many times I initiated a code blue call and have participated with the resuscitation team. Most of the patients that I have involved in code blue have died during the resuscitation process with a huge mess of blood, airway secretion, urine, bowel movement and medication on his or her body or survived less than 24 hours. After each resuscitation action, I felt emotionally drained, depressed, guilty, helpless and frustrated with the code status decision - "Full Code". In this paper, by presenting a resuscitation scenario, I will conduct a discourse analysis about this clinical dilemma from both liberal-humanist and scientific-medical perspectives. Through analysis, I understood that clinical dilemma happens all the times, and it also will happen in the future. Nurses need to seek how to explore the contradictions or tensions from different discourses and understand them to grieve over. At the end of the paper, I discuss the implication of the future nursing practice based on the knowledge acquired from this discourse analysis.
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It was my first year in an adult inpatient medicine unit after my graduation from a nursing school. Mr. D was a 97 years old widower. He was admitted to the hospital for congested heart failure, shortness of breath and also found to have pneumonia. He was intubated for respiratory difficulty in the intensive care unit then eventually developed multisystem organ failure, sepsis, and meningitis. Also, he was at the end stage of liver disease, and illustrated by brain damage signs from circulating toxins, hepatic encephalopathy. Arriving at my unit, he complained of shortness of breath and dizziness. His jaundiced skin glowed bright yellow. He showed delirium, repeated the same questions in slurred voice incoherently. He presented a marginal blood pressure, lungs were full of fluid, and oozed blood from his gums and injection sites was hardly to clot. All his limbs were extremely swollen. Nasogastric feeding tube was in situ. Oxygen was supplied at 4-liter by nasal prongs with saturation of 88 - 92%. While checking orders to create a Kardex, I realized his code status was "Full Code", and physician's progress notes indicated that decision of code status was discussed between health care team and family three times.
Two days later, I found Mr. D was not responding to my greeting and touch during my hourly round checking at 10:00 in the morning; no breathing sound heard, and no palpable pulse. I hit the code blue button on the wall at beside and started CPR. A "code blue" announcement automatically was delivered through overhead speaking system. Code team arrived in one minute. Night gown was stripped off; an aged body was totally naked. Deep suction via yankauer was made in rush, a tube was inserted down his throat, and then into his lungs in a harsh manner, and a ventilator took over his breathing, blood noted in his mouth; a cardiac monitor was hooked up to his chest; chest compression was made in a powerful manner to reach the depth of 5cm, rib and sternum bones broken noise was heard; a big needle-like catheter for getting artery blood gas by a respiratory therapist was poked into to several locations, blood contaminated his right upper arm and inner thigh; venopuncturing for intravenous cannula insertion by a nurse was re-poked four times on both extremely swollen arms and blood messed on forearms; isosource of nasogastric feeding came from his nose and mouth, foul odour smelled; epinephrine was injected two times; defibrillator was applied three times with strong electric shock. Twenty minutes later, the physician ordered to stop the resuscitation effort and give up. Mr. D was left naked in the bed, lying without moving, deadly pale on his face. Everybody was exhausted, leaving the room with disappoint on face, and huge mess on the bed and floor. Tears were running down in family's cheek, too sad to say a word.
Analyzing Personal Struggle
Full code is permission for a code team to insert a ventilation tube into failing lungs, apply electric shock to a fibrillating heart, and unleash a extra blood of punctures, dissections, and exsanguinations on the human body. A resuscitation based on "Full Code" is supposed to be performed aiming in offering the patient a benefit. However, these interventions are marginally effective (Hiberman, Kutner, Parsons & Murphy, 1997; Perers, Abrahamsson, Bang, Engdahl, Lindqvist & Karlson, et al, 1999), lives saved and functioning restored only for a small number (15% worldwide average) of people (McGrath, 1987; Saklayen, Liss & Markert, 1995; Schneider, Nelson & Brown,, 1993). Subjecting a dying person to CPR who is believed there is virtually no hope of survival is a terrible way to practise health care; it is inhumane; and it is an assault. Despite significant improvements made in training, equipment, and drugs, the overall CPR survival rate has remained almost the same over the past 30 years (Beall, 2001). Findings from 33 studies showed that about 16% of patients under age 70 and 12% of patients aged 70 and older survived CPR only (Kaye & Mancini, 1996).
After participating in the resuscitation for Mr. D, I have been struggling over this real scenario at: (1) what is the quality of death; (2) who can decide the code status; and (3) what can I do for advocating my patient?
As a nurse, I have to deal with life-and-death decisions with each of my patients. With the participating in the resuscitation for Mr. D and witnessed his death, I am wondering: what is a "quality death"? What a kind of process is a "quality death"? Who defines it? What is the resuscitation doing? How much do patients in terminal life stage have to understand about what dying is like? How well patient's dignity could be preserved and integrated into the resuscitation process? How well patient's wish could be respected in the decision of code status? How does a patient want everything to be done to extend his life - "Full Code" in hospital parlance, or a patient wants to let his/her death happen naturally without interference - a "Do Not Resuscitate" order? Does the "Full Code" status really benefit the patient's interest or just benefit a substitute decision maker's/family's interest? As for Mr. D's scenario, is the "Full Code" status his real wish? Is the dying process his real belief about dying? Is the dying process his real value about the death? Did he image his death with broken sternum and ribs, massive blood mess and contamination? Did he image that, at the end of life, he was surrounded by the code team rather than by his family members? Unfortunately, I have no solution to seek the true answers yet; I felt the contradiction and tension between the resuscitation on behalf of a "Full Code" status and quality death: professionally, I have "duty of care" to participate in the resuscitation action and do whatever required for such a purpose, but ethically and morally, I do not want to do any harm on my patients during the resuscitation. It has become my clinical dilemma of struggle for many years.
The decision of code status is a complex and controversial topic. Theoretically, it seems simple and easy to declare either patient or patient's substitute decision maker will be the subject to make decision about code status. However, in the real working environment, I noted that many patients' indications on code status are blank, not checked yet; and sometimes they are left as blank for a long period; also, some patients' code status has been changed reversely from "Do Not Resuscitate" to "Full Code" by their family; Mr. D was one of such examples. It tells me that the decision process in not a straight-forward linear procedure; it is organic or dynamic. The confusion for me is who is the real decision maker during this organic process, the patient own, patient's family/substitute decision maker or a health care provider? As a regulated professional, a health care provider is rarely taking action as such decision maker; usually, either patients or their family will be. While the patient is capable, it is clear that the patient decides it for himself or herself. However, my wondering is that there are so many factors that will impact patients' capacity when decision needed to be made on the code status, such as age, medical condition, the quality of life, religious views and overall wishes. Further more, like the perception on pain, capacity is really subjective; a sound judgement on patient's capacity also is difficulty. Who can decide a patient's capacity is either intact or impaired without any interest conflict? Like Mr. D's scenario, due to his senior age and confused medical condition, his daughter was his decision maker from the admission; the reality of his condition was recorded as deteriorated daily, and he had been incapable to provide any input about his code status; the progress notes show us that his code status has been changed from "Full Code" to "Do Not Resuscitate", and then back to "Full Code" again during a five-week period of hospitalization. Is there any interest conflict in the process while his daughter made decision of turning over on his code status for him, and does such change will really benefit him in relieving suffering, restoring functioning and improving his quality of life?
As a member of heath care team, what I can do to advocate my patients' decision is really limited so that I am feeling helpless. Being a sick people in a hospital might be very stressful; in additional to physical symptoms, people may feel anxious, depressed and helpless. Also, family members might be place under a difficult time and position during a medical crisis; family members may disagree, emotions might be high and medical information can become confusing agent. In such a stressful circumstance, any possible irrational decision could be made without considering the reality and possibility. Perhaps, we can say nurses are knowledgeable to provide information, as well as nurses know more about the patients' daily condition than a physician so that a nurse really can make some good input for health care team and family in decision-making to advocate patient's benefit; however, the final decision is totally depending on patients' or their substitute decision-maker's understanding about the context of code status; they are legally granted the power. Like Mr. D's case, his decision-maker alternatively requested change of his code status from "Do Not Resuscitate" to "Full Code" on his behalf that resulted in futile and miserable resuscitation, even if his most responsible physician could not apply any influence on it. Health care providers are not legally granted such a power, and ethically, we also can not apply our opinions, judgement or choice on patients' or their decision-maker's decision. So, I have been struggling over the relationship between power and knowledge; under such circumstance, knowledge is not and does not have the power at all. What we can do is through information providing to empower our patients or their decision-maker to use their power to make a right choice on code status to avoid such futile and miserable resuscitation happened on Mr. D without any benefit, but harm.
Exploring Discourse Analysis
The clinical dilemma as identified in the above scenario, the contradiction and tension are mainly triaged from respecting the patient's own or their decision-maker's choice on code status while providing our resuscitating intervention. In order to understand the issue, I did literature review on decision making on code status choice. I chose the patients' or their decision-maker's decision of choice on their code status and how to empower them in making a right decision by information providing to advocate for patients' benefit in quality of life at the end of life as my focus. In the following sections, I will use Mr. D's case to analyze this clinical dilemma from both liberal-humanist discourse and scientific-medical discourse perspectives.
Scientific-medical discourse: empower patients to make right choice on code status
According to Grant, Giddings & Beale (2005), the scientific-medical discourse is based on the biomedical mode of medical science. Its core concept is that a human body is a collection of different parts that are organically organized and form different systems that manifest as a set of symptoms (Brown & Seddon, 1996, a, b). It constitutes the scientific fundamentals and becomes the root of nursing science (Grant, Giddings & Beale, 2005, p.499). That is the reason I chose it as one of my discourse.
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Medical knowledge explicitly tells me that life maintenance must be under the control of homeostatic balance, which is maintained by normal functions of all organs; and homeostatic control mechanism can maintain only in a relative narrow constancy (Thibodeau & Patton, 2005, p.16). CPR is a desperate technique that is used on the people who are might be suffering cardiac arrest in order to deliver oxygen to blood stream and maintain a cardiac circulation to keep vital organs, such as such as the brain, be oxygenized to be alive, to delay brain death, and maintain the heart to remain responsive to defibrillation; in many type of patients, it virtually never works; for a patient with an advanced age and life-threatening illness who is dying of the underlying disease, there is very limited benefit because survival is rare (<1%); patients, even health care professionals, largely over-estimated its function as an global or universal resuscitation technique (Hayward, 1999). Dr. Bishop, Brothers, Perry and Ahmad (2010) also argued that patients in their final stages of their lives would finally reach the point of cardiac arrest, and CPR is a desperate, invasive medical intervention which for many patients has a remote chance of success. As for Mr. D's case, my assessment tells me that his coming death is the normal human body deterioration related to his aging, irreversible function ability losing of multiple organs; the given resuscitation action driven by his "Full Code" will be futile and can not make any sense to bring him back to alive, but impairing on his quality of death into an indignity process. That makes me feel frustrated and helpless at not only the intervention I have to take without scientific rationale, but also the intervention will bring some harm on my patient for no benefit.
As articulated by Grant, Giddings and Beale (2005), "nurses had sound technical knowledge of bodily diseases, the associated symptoms, predisposing causes, and appropriate treatment" (p.499) from medical science. Under the influence of biomedical model ideology, the interventions of nursing care have been constructed as a set of tangible, specifically operate-able and measurable procedures that are implemented in a methodical manner - step by step, for example, nursing process. Reflecting on Mr. D's case, by informing them the updated condition and possible prognosis through my careful and objective assessment, I can support my patient or their decision-maker to choose a right code status to avoid a violent death that occurs during an advanced cardiac life support and artificially prolonged life maintenance. It is not to apply my opinion or choice on them. It is to empower them to make right choice in a supportive manner to preserve patient's dignity and quality of life, as well as death. In such a way, my professional integrity also will be benefited in maintaining, professional contradiction and personal tension will be avoided.
Liberal-humanist Discourse: Advocating Patient
According Grant, Giddings & Beale (2005), the liberal-humanist discourse of nursing care is a holistic approach; the patient is viewed as a whole person and a unique individual, not the collection of different parts only. Empathic nursing care does not only deal with patients' biomedical issues, but also emphasize patients' autonomy, rationality, emotions, understandings and dignity; it is characterized by respecting patient's self-determination, free choice, and self-representation (Praeger, 2002). The ethic ideology of liberal-humanist discourse of nursing care is underpinned by two assumptions: nurses' commitment to a trust therapeutic interpersonal relationship of care and having moral obligation to act (Dyson, 1997, p. 200) on behalf of patients (Grant, Giddings & Beale, 2005). Such a sound holistic approach becomes the grand rationale I choose it as one of my discourses. Also, it casts and shapes my best nursing practice by providing my patients and their family holistic caring.
However, it must be understand that such an universal or global ideology itself has an underlying contradiction and tension that I experienced in my patient Mr. D's scenario, that is, under some circumstance or specific context, it is difficulty that empathetic nursing care must have commitment to trust interpersonal relationship by respecting the patient's autonomy and at the same time, nurses also have moral obligation to act on behalf of the patient.
As for Mr. D's case, health care team discussed the code status choice in multiple family meetings based on informed decision principle. The whole caring process demonstrated the empathetic caring by respecting family's decision on the code status choice, taking appropriate and timely resuscitation action morally on behalf of the decision maker. However, the misery result was the violation of patient's dignity and quality of death in the dying process, which is actually avoidable and it morally generates the ethic guilty and tension in health carer's emotion, because health carer eventually does not have the legal authority to take action to morally prevent such an avoidable misery event to be happened. Such contradiction and tension in professional, legal and ethic principles basically contribute to my distress and confusion.
Implications for Nursing Practice
The discourse from either scientific-medical approach or the liberal-humanist approach, while people's life reaches the end stage life-span, not only does the physical body, but also the person as a whole, become a vulnerable object. Being a ill person in a hospital can be terribly overwhelming with physical symptoms, anxiety, depressed and helpless, as well as invasive treatment, diagnostic interventions and a variety of information that is related to each procedure. A treatment is supposed to be of benefit if it relieves suffering, restores functioning and improves quality of life; it will become a burden if it causes pain, prolongs dying without offering a benefit or increases distress. When we emphasize that patients do have some control over what kind of treatments they do and do not want, but in how many cases patients really implement their control over the treatments? Taking Mr. D's scenario as an example, being in his senior age and impaired cognitive status, it is impossible for him to be a host to get his treatment and care plan under the control of his wishes; his decision maker on his behalf, driven and masked by a general graceful desire that is often seen in the most of people, just wants "everything has to be done to remain alive" to save and prolong his physical life, even if a few more minutes, legally places not only his physical body, but also "a person as a whole" at the risk of vulnerable position unconsciously while choosing a "Full Code" status. As a nursing member of the code team, I have "professional obligation" to do some inhumane resuscitation actions on his vulnerable body and impair his dignity of death. So, putting myself into Mr. D's shoes, if either my parents or I were in his age and health condition, I really need the preservation of self-determination, free choices and self-representation in decision making on code status choice - choose "DNR", let me go naturally without pain, suffering and inhumane resuscitating effort.
Our patient-center nursing care philosophy always makes us be aware of that patients need to be supported, not blamed (Kammerer, Garry, Hartigan, Carter & Erlich, 2007). From the liberal-humanist discourse of nursing care views, committed to trust interpersonal relationship with patients, empathy and communication are two core concepts. When a person's life is at the brink of death, a clear mind is a rarely existed. Often, it will be more difficulty to accept and respect a frail mind than a frail body. Terminally ill people may look differently, feel even worse and terrible, and think in another way. They need advocacy, protection and caring in humane, patient, and professional ways. Supporting their ability to get their lives under control is no less important than keeping their blood pressure under control. Communication in an empathetic passion is more conducive to doing the right thing than rigid legal documents. Nursing has moral, as well as professional, obligation to communicate our scientific-medical knowledge to support patients in determining what kind of code status they want to be and make their wishes known to their loved ones. Family is an integrated part of our clients, which are facing a difficult position during a medical crisis. Identically, we have above obligation to support patients' family members in knowing what a loved one wanted that will help them get peace of mind that they are honouring the wishes of their loved one. In such a way, our professional development will be in growth, and our personal distress that is involved in the discourse tension will be released.
According to the learning goals of this course, discourse from scientific-medical approach and liberal-humanist approach on a real clinical situation is presented in this paper. Personal distress, frustration and confusion arisen from the clinical dilemma have been analyzed. Nursing care can be explored from different kinds of contradictory discourses. All these contradictory discourses might contribute to nurses' feeling of distress, frustration or confusion when encountering different clinical situations. The liberal-humanist ideal of ethic of care focus on viewing a person as a whole and respecting patient's self-determination, free choice, and self-representation, bur patients need advocates and support from scientific-medical approach in decision-making. Furthermore, for professional and personal development, nurses should learn to understand these different discourses in one situation and take effective strategies to solve the clinical dilemma. Committing to a trust therapeutic interpersonal relationship with patients will help nurses understand patients better, and it also helps nurses to find the meaning of the event so that effective solutions could be figured out to solve clinical dilemma.
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