Skip to main content

Code Blue




by: Marcia Glass, MD

I sometimes notice “DNR” on my intern’s to-do list during rounds. It usually means his resident asked why this patient, in spite of being so debilitated from his end-stage cancer, or his dementia, or his heart failure, was still full code.  The patient should be made DNR instead, but doing so involves a difficult conversation with sick patients or desperate relatives, sometimes over hours, sometimes over days. Hence, the DNR on the to-do list and the knowing looks from my team. “How’s the family?” “Do they get it?” “Are they reasonable?” Any possibility of a peaceful death depends on my medical team’s ability to make people we hardly know trust us and then change their minds.

Mrs. J. was different. In her eighties, she came to our hospital in San Francisco with her favorite blanket and a book of crossword puzzles. Her husband, close to ninety, rode two buses in his neat overcoat every day to arrive promptly at 8 a.m. before our rounds started. Mrs. J. had advanced stomach cancer and knew she was dying. She had been on home hospice care and came in only to see if the surgeons could relieve her agonizing intestinal obstruction. They could not. But they did place a nasogastric drainage tube to make her more comfortable. My team adjusted her pain and nausea medications and found a hospice facility where she could be cared for until she died, instead of struggling at home. She was not fighting to stay alive; she only wanted to feel better and enjoy the limited time she knew she had left. She was eager to leave the hospital and spend her last days at the residential facility we had found for her. She had told us not to resuscitate her if she coded. She was at peace.

The one morning her husband came in late, I sat alone by her bed and asked how her night had been. We ask these questions dozens of times a week, but this encounter felt more intimate, chatty. For a moment, I enjoyed a friendly conversation, a rare pause in the day when I could sit next to someone I was caring for with no agenda. For ten minutes, no one came by to clear the breakfast tray or encourage her to sit up for physical therapy or ask her to swallow her every-four-hour pain medication. We could have been in her living room instead of under the fluorescent lights of this hospital. But then the speakers in every hallway came to life, and we heard the urgent call to a code. Code Blue. 10th Floor ICU. Code Blue. 10th Floor ICU. The announcement sounded calm, formal, aseptic. Yet the clean language belied the chaos I relive every time I hear a code: nurses shouting, doctors running, a defibrillator charging, blood everywhere. I looked at Mrs. J. and realized she seemed scared. She closed her eyes, grabbed my hand, and whispered something to herself, too softly for me to hear. These could have been words of relief that she would never go through a code, or words of compassion for the person suffering a few rooms away, or, perhaps, some doubt about her decision to pursue comfort measures only and not cling to every possible second.

I have helped many other patients and their families struggle through decisions about end-of-life care over the years since I cared for Mrs. J. As I have supported them through this grueling process, Mrs. J. sometimes comes back to my mind. I will never know what she felt when she heard someone else’s code blue, but I will always remember what I thought at the time: You made the right choice.



Comments

Paula Jacunski said…
As a nurse, I've found that usually patients and families don't understand what is involved in resuscitation. They don't know what they're agreeing to. When you explain it to those that want to hear it, the drugs and equipment used, they at least have more information to make a hard decision.
Lori said…
Loved your post. We as health care providers get to see multiple ways to die; our patients only know their own one experience. It is a challenge to explain and guide them through the choice process. Thanks for your thoughts.
Zach said…
A fascinating, informative piece. Thank you for sharing your perspective!
Bart Windrum said…
Thank you for framing end of life choices in terms of dying in peace. This is the frame I've used since transforming into a lay end of life activist after the non-peaceful, supposedly advanced planned, hospitalized demises of each of my parents (2004, 2005). Absent the clarity your patient embodied, pathways to peaceful dying involve recognizing and overcoming obstacles. Anyone curious see www.AxiomAction.com .

Popular posts from this blog

The Future of Palliative Care: A Podcast with Diane Meier

There are few names more closely associated with palliative care than Diane Meier.  She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC).  We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including:
What keeps her up at night?Does palliative care need a national strategy and if so why and what would it look like?The history of CAPC and the leadership centersAdvice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careersWhat she imagines palliative care will look like in 10 or 15 years?What is the biggest threat facing palliative care? So take a listen and if you want to dive a little deeper, here are two articles that we discussed during the podcast:
A National Strategy For Palliative Care. Health Affairs 2017Palliative Care Leadership…

Advance Care Planning before Major Surgery: A Podcast with Vicky Tang

This week's podcast is all about the intersection of geriatrics, palliative care, advanced care planning and surgery with our guest Dr. Vicky Tang.  Vicky is an assistant professor and researcher here at UCSF.  We talk about her local and national efforts focused on this intersection, including:
Her JAMA Surgery article that showed 3 out of 4 older adults undergoing high risk surgery had no advance care planning (ACP) documentation. Prehab clinics and how ACP fits into these clinicsThe Geriatric Surgery Verification Quality Improvement Program whose goal is to set the standards for geriatric surgical care including ACP discussions prior to surgeryHow frailty fits in and how to assess it (including this paper from JAGS on the value of the chair raise test) So take a listen and check out some of those links.  For those who want to take a deeper dive into how GeriPal and surgery fit together, check out these other podcasts: Zara Cooper on Trauma Surgery, Geriatrics, and Palliative Car…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …