The outcome may depend on the physician’s comfort with discussing the DNR process with family members, said a Canadian critical care nurse. “Patients have told me they wanted a DNR because they ‘can’t take it anymore,’ but doctors have overridden the patients’ decision because they said I was ‘playing God’ by advocating the patient’s request to die peacefully,” she said. When a Maryland hospice nurse told a physician that her patient had an advance directive for “no life-support measures in an end-stage condition,” the doctor replied, “I am not a lawyer,” and resuscitated the patient anyway.
The hospice nurse said that the waters would be less murky if doctors told patients’ families, “Your loved one filled out a form after a conversation with her physician that said she would want only comfort measures at this time. We would like to honor those wishes.”
Nurses also wish that healthcare providers did a better job of explaining resuscitation efforts to families, and that family members had more honest end-of-life discussions with each other. “I think if people better understood exactly what ‘do everything’ entails, they would be less likely to demand it,” said the Texas travel nurse. “Performing CPR is probably going to break multiple ribs, [some patients] will almost certainly die in the ICU after a prolonged barrage of horribly toxic medicines, and we can put someone on a ventilator but their anoxic brain injury means they’re never waking up again. If we could show families how much more horrible it is to prolong treatment of a dying person, perhaps they would choose differently.”
There are “codes” . . . and there are “slow codes.”
Some medical teams have a hush-hush way of dealing with discrepancies between a patient’s DNR and family members’ demands. In some hospitals, as a Missouri nurse told me, “there are lots of unsavory things that the polite public would make hay with,” including the slow code, a little-known term to the general public. Various units have different designations; at a Canadian hospital, medical teams distinguished between a full code, which they called “code 55” and a slow code, or “code 54.”
Some physicians will unofficially call a “slow code,” which will never appear in a patient’s chart, if a coding patient is elderly or chronically ill. The signal notifies a team that they are not expected to revive the patient but should go through some of the motions anyway. “Responders literally walk slowly, are slow to respond, give medications slowly, or hesitate to intubate so that the patient is unlikely to be revived,” said a Midwestern nurse.
“It’s often for the sake of a family who needs to see us doing something, anything,” said the Texas travel nurse. “We do [these things] when it’s painfully obvious someone is so far gone they can’t be saved, and occasionally when the patient is a DNR. The CPR and meds are the same, because it’s a dangerous line to cross if you withhold standards of care, but if it’s a young, healthy guy, we might code for 45 minutes, whereas with the elderly terminal DNR we will only code for 10. Usually we do a round of CPR, check for cardiac motion on the ultrasound, and then call it.”
A Midwestern nurse said the slow code is “not ethically appropriate” and used only by certain teams. As a Washington State PACU nurse explained, “Pounding on the chest of an extremely frail, elderly person is torture, not lifesaving. In instances when family members insist that we do all to keep them alive, it’s understood among the staff that the patient is a ‘slow code’ and no one hurries to get a crash cart. We do, of course, make the patient as comfortable as possible.”
We do not treat all patients equally.
Nurses work hard to give patients the best healthcare they can. But not every patient gets the same treatment. Respectful patients might get faster, kinder service than the pain-in-the-ass down the hall; grateful, thoughtful patients might get some additional perks: extra snacks, the newest DVD releases from the library, the best magazines from the waiting room, additional diapers in the postpartum ward. “I’m always happy to get something for the patient if it will make them more comfortable or make them smile,” said an Arizona pediatric nurse. “When an able-bodied parent asks me to fill the water pitcher because they don’t want to walk to the galley to fill it themselves, I get just a little pinched. The hospital is not a hotel, and I’m not your personal butler.”
The secret is simple. If you’re not nice, said a travel nurse in Colorado, “rest assured that every single person involved in your care will know about it. While we will never cut corners on medical care, you can be damn sure we won’t be doing you any favors or even acting as if we like you. You’ll get your extra cup of soda or warm blanket a lot quicker if you’re not a dick. Also, we won’t talk about you in the nursing station if you’re nice. We reserve the trash talk for the mean ones.”
And sometimes we are told to treat certain patients better.
Many hospitals treat VIPs better than the average patient, saving deluxe private rooms for celebrities and officials who know about them. While some luxury rooms are available to any patient who can pay, like those in the Johns Hopkins Hospital’s Marburg Pavilion, others are kept secret.
Nurses described accommodations that look more like spacious luxury hotel suites than hospital rooms, with kitchenettes, beautifully glass-tiled bathrooms, and other amenities. In one Washington State hospital, when a VIP comes in, the staff combines two rooms to make a large one. They are instructed to bring in a large-screen TV and the “VIP furniture.” After the VIP is discharged, a nurse there said, the furniture is removed and stored until the next VIP admission. “They do this for rich and influential people and we nurses are disgusted by it. Nurses are taught to treat each patient as an important person and to give our best care to each one of those patients. Personally, I find it insulting to our profession,” she said.
A Washington, DC, hospital has a VIP unit devoted to patients such as visiting foreign dignitaries, senators, and professional football players. “It doesn’t have typical hospital furnishings; the rooms are much bigger, with fancy bedspreads, decorative pillows, and lavish curtains,” said a Maryland nurse who used to work at the hospital. “The patients are served excellent food—much better than the food on the regular floors—and the nurses cater to their every whim. It’s a restricted floor, with no access from the regular elevators. Most people don’t even know this floor exists.”
In California, celebrities have been offered their own private nurse; one nurse said that her hospital “definitely bent over backward for anyone they considered important.” In other states, some administrators give nurses special instructions when VIPs arrive and will personally check in on the patient. When the nurses give report, they are supposed to remind the incoming nurse that the patient is a VIP.
VIP care becomes problematic when those patients unnecessarily take up resources that more critical patients need. “Sometimes they will get a one-on-one nurse or we are all told to give them extra-special treatment,” said a New Jersey nurse. “They can’t hold back a room in the ICU, but I have seen critical patients who should be next to the nursing station moved so that a relation of a board member, a big donor, or celebrity could have the better room even if their condition didn’t warrant that level of observation. At another local hospital they had an entire VIP section set aside; those rooms were not to be used for the riffraff.”
Every hospital at which a Virginia nurse has worked had “a couple of rooms, if not a floor, dedicated to VIPs, which is often hidden. At one hospital, there was a room specifically maintained only for the use of a very famous person with a very crappy heart. They’ll get the best food, the nicest rooms, the most accommodating physicians, and the nurses who are easiest to push over. The hospital left the VIP section completely empty unless a VIP was present. No intermingling. Politicians have such a warped sense of how the healthcare system works, because they never have to be part of the actual system.”