Code Gray

- Description
- Reviews
- Citation
- Cataloging
- Transcript
If you are not affiliated with a college or university, and are interested in watching this film, please register as an individual and login to rent this film. Already registered? Login to rent this film.
ACADEMY AWARD NOMINEE! This multi-award-winning program documents four actual situations where nurses confront difficult ethical decisions, as they balance the often contradictory views of patients, family members, and other staff about what is best for their patients.
In the case of a newborn with profound and probably fatal birth defects, nurses must decide what level of care represents beneficence, or 'doing good.' The staff in a nursing home must decide between respect for a patient's autonomy and the need to restrain her to prevent injury. Nurses in an intensive care unit make daily decisions about the allocation of beds and nursing resources in accordance with the principle of justice. A nurse caring for terminally ill patients faces a conflict between fidelity to her commitment to relieve suffering, and the promises made to the patient's family.
Code Gray offers no easy answers to their questions. It is designed to trigger discussion among nurses, physicians, other health workers and consumers about the realities of nursing in a technologically complex world. It will be invaluable for students preparing to enter the healthcare professions.
'A compelling film about the realities of nursing in a technologically complex world, where the humanity of both patients and nurses is often in jeopardy.' -Mila Ann Aroskar, Society for Health and Human Values
'Acknowledges the crucial 'here and now' bedside decision making nurses routinely shoulder, and caringly illuminates the hidden responsibilities of nursing.' -Booklist
Citation
Main credits
Sawyer, Joan (Producer)
Sawyer, Joan (Director)
Achtenberg, Ben (Cinematographer)
Achtenberg, Ben (Film editor)
Mitchell, Christine (cmm)
Other credits
Photographer/editor, Ben Achtenberg; music, John Kusiak, Robert Van.
Distributor subjects
Bioethics; Death and Dying; Ethical Dilemmas; Ethics; Fanlight Collection; Health Care Issues; Issues and Ethics; Medicine; NursingKeywords
Code Gray
[00:00:02.48] [HEART BEAT]
[00:00:26.75] To me, one of the most difficult thing that staff nurses have to deal with is ethical dilemmas. Once they've been here six months to a year, and they've got the technology down pat, then you really get stuck with the why, and the "what am I doing to this person," and "what is this person experiencing?" you've got to be able to cope with that and live that in order to stay at at the bedside.
[00:00:52.57] There's so many pros and cons. And even though you make a decision, it isn't necessarily the correct one.
[00:01:01.81] I may be wrong sometimes, and going ahead and giving aggressive therapy to someone, and prolonging their life, and making them suffer. In that case, maybe I am taking the family's side about the patients. A lot of times, patients in the IC that we feel that way about, then you're in a real gray area.
[00:01:23.78] Even when you make the right decision on an issue, you might still face tragedy and loss, and guilt. Nurses see a lot of tragedy and suffering. In some ways, I picture the hospital as an institution which draws and concentrates suffering into one place. And nurses, therefore, are specialists in suffering. They kind of sweep it up on the wards. They come and talk with ethicists and say, what am I supposed to do with all this suffering?
[00:01:54.09] I think ethics offers clear thinking about these decisions, some perspective on their nature and their ancient history, some comfort, and clarity about choosing directions in face of uncertainty.
[00:02:15.15] The principle of beneficence encompasses the idea that we are to avoid harming patients, and that we are to do good for them.
[00:02:39.25] TJ was born with severe birth defects. Even before she was born, her mother had decided to give her up for adoption. And so TJ is a ward of the state. TJ is profoundly retarded, and she'll probably never be able to see, hear, walk, or talk. She can't suck, and vomits back her feedings. And the nurses have to decide how aggressive to be in feeding her.
[00:03:11.57] It's also very risky for the nurses to even hold TJ, because when she's taken out of the Isolette her temperature drops dangerously low.
[00:03:22.48] What we're trying to do now is wean her from the Isolette. And we've tried to do that several times, and it's just not working. She was out yesterday, and her temp went down this morning. After 24 hours, it went down to less than 35. So for feeds for you, I put her back to SMN.
[00:03:42.31] So on the one hand, you want to say one thing, that the child's best interest is perhaps not treating him, because of the possible pain or suffering. And on the other hand, we've got the concern about whether not treating her is wrong. And that's what there's some disagreement about.
[00:04:02.08] Janet is TJ's primary nurse. Jean is another nurse caring for TJ. The nurses involved in this case have to figure out what it means to care compassionately for this child. What their obligation to do good for her actually entails in nursing practice.
[00:04:22.96] As far as I'm concerned, it's feeding. Feeding is really an issue. And keeping her warm. If you don't do that, then she is going die. And if she's going to die anyway, then let it be from something else, but not from lack of what I consider to be just basic nursing care.
[00:04:38.62] I feel to some extent, that if she is going to die, that we could allow her to die, even if it is by dropping temperature, or the by the fact that she's not tolerating it. If it's a course that's naturally going to occur that she is going to die, that we're just prolonging that. We're extending her life.
[00:04:56.07] I guess I'm torn between what is causing the most harm, putting the tube down, giving her food, and having her vomit, or just not bothering with that whole process to begin with. Putting a tube down your nose is a painful procedure. And it's, to me, aggressive. And I don't want to start doing that with her. And I don't feel that even if she does live very long, the quality of her life is going to be very good. I just feel we should do comforting actions with her, as far as holding her and trying to feed her, but not doing a lot of aggressive tests with her.
[00:05:28.36] We don't know if she's going to live or not. That's the whole point. I feel comfortable when I know she's eating. When I feed her, and she doesn't take it, my instinct is to put a tube down, and make sure that she gets it one way or another. I don't feel that that's aggressive. Jeanie does. To me, it's just maintaining her. I just can't feed her, and watch her either vomit it back or take it, and then know that she's dehydrating. Because I feel that if she's dehydrating, she's going to die, and that I'm a part of that.
[00:05:59.70] I don't think anybody has problems with the idea that she may or may not die. Nurses deal with dying patients, even little kiddies, all the time. I mean, that's nothing new to nurses. All we really want to do is not to do anything heroic. We're not talking about codes. We're not talking about anything that's dramatically. We're just talking about, let's try and get her to keep her food down, and then to keep her warm.
[00:06:19.99] I don't think that you need to put someone through a lot of traumatic experiences if it's not going to do them any good.
[00:06:27.48] I don't feel that I'm aggressive at all, but looking to you, maybe I am.
[00:06:31.78] But that's the nature of a dilemma, to be able to see both sides as justifiable.
[00:06:37.29] But it's a horrible proposition to be, when you are the one that, you see three sides. You see that all three would be correct. And yet now, here you are. You're the one that has put things in writing, and it's your care plan, and you're the one that's making recommendations.
[00:06:50.29] Is there any possibility that a joint conference would be useful?
[00:06:55.08] The nurses that presented this case brought us some of their own ethical concerns about the case. This child raises issues that makes it difficult for us to know what will influence our decisions.
[00:07:06.11] Should you push the feedings on the baby, even though they're probably not doing any good, just because it makes you feel that you're giving the baby some nutrition? And if the primary nurse determines that a certain route should be taken, other nurses may have difficulty dealing with that. In other words, if I feel that the baby should be hydrated and have adequate nutrition, other nurses might feel that it's imposition to the baby to feed it, or to risk aspiration.
[00:07:31.91] In this case, what you're saying is, should we substitute comfort for whatever longevity this child's going to have? Do you we take more risks with her life than we would with another child's life in the interests of more comfort in the short run, since we don't have much hope for her in the long run? Which is very much a nursing decision-making issue, as opposed to a traditional medical decision-making issue. It's the here and now bedside decision-making. It's ongoing, and it has to be very private. What a doctor writes in the order book is rather exposed, but a nurse alone in a room with a patient has a lot more conscience to contend with.
[00:08:11.81] The principle of beneficence, or doing good for the patient, sometimes conflicts with the principle of autonomy, that we are to respect the patient's freedom to make choices.
[00:08:36.41] OK, Olive. Recently, you've had some problems with close calls as far as falling goes, because you're not as steady on your feet as you used to be.
[00:08:44.91] You remember I fell.
[00:08:46.11] Yeah. So I think that probably now's the time that we should consider maybe a restraint.
[00:08:51.93] No, I don't want to be tied down.
[00:08:54.54] Well, this isn't really to tie you down, Olive. We're going to use this as sort of a reminder, so that you don't get up without ringing your bell so one of the nurses can come walk with you.
[00:09:04.11] You know, I have the feeling that as long as I can do things for myself, I don't want to be bothering somebody else. I get my exercise by walking down the one corridor, and then back, and then down the other corridor and back, upstairs here, and then down on the ground floor too.
[00:09:22.50] You'll still be able to do that, Olive, only you'll have company. OK, Olive. This is the belt that we're going to use.
[00:09:28.99] I don't wan tit.
[00:09:29.72] I know you don't want it. But you realize how important it is. If you should fall, you're going to break something. And then, it wouldn't be a matter of when you wanted to get up. You'd probably be in bed, and we don't want that to happen to you. But you'll always have your bell cord that you can ring for a nurse.
[00:09:46.45] I'm not going to be restrained.
[00:09:48.29] Sharon has to weigh her obligation to respect Olive's freedom against her obligation to protect Olive.
[00:09:57.00] It's always a hard decision to make. We'd rather have everybody just walking around and doing as they saw fit, because this is their home and we like to maintain that, as long as it's absolutely possible that they'll be comfortable here, and to be able to come and go, go outside, visit family, friends, come back, go shopping. That type of thing. And it's a very difficult decision to make when a patient reaches the point where they just can't handle it anymore. And it's taking away a freedom from them that nobody really wants to take away.
[00:10:27.91] OK, Olive. This is called a Posey belt. Now you can wear it underneath your clothes if you like.
[00:10:33.89] That would be a good idea. Then it wouldn't--
[00:10:36.08] It wouldn't show.
[00:10:36.73] Show.
[00:10:37.08] OK. Lift this up. There. See, we'll put this part in the front, so you don't even know you've got it on.
[00:10:47.32] Except I do.
[00:10:49.29] You think you can live with that?
[00:10:51.13] I guess so.
[00:10:52.01] We'll try it.
[00:10:52.98] I'll try.
[00:10:53.62] OK. So I'm going to go now.
[00:10:56.42] Are you going to leave this thing on me?
[00:10:58.24] Yes. I'm going to leave it on now for a while.
[00:11:05.57] Another patient in the nursing home is physically fit, but mentally confused. The nurses have to decide how far they should go in protecting this patient, and how far they should go in protecting other patients from her noisiness and her wandering.
[00:11:25.55] [SCREAMING]
[00:11:35.65] I have to make a decision this morning.
[00:11:37.41] [SCREAMING]
[00:11:40.84] Either we keep her, and she changes her mind, and is willing to stay.
[00:11:46.92] I don't think she's responsible enough to make that decision herself.
[00:11:50.62] We keep her and medicate her, and probably restrain her at the same time.
[00:11:55.40] We take a woman that's fairly alert, and make her a bed patient.
[00:11:58.64] And who is physically in great shape and able to wander up and down the halls without a problem at all.
[00:12:04.44] A lot of the nurses are opposed to medicating a person like that, but we probably would have no alternative.
[00:12:10.57] It's a hard thing. It's something I do very reluctantly, even if the orders are there.
[00:12:16.15] Physically restraining her doesn't even seem as bad as the chemical--
[00:12:20.38] The chemical, where she has not had the opportunity to fight it off.
[00:12:25.94] Right. And it has some side effects.
[00:12:28.67] You can change a whole person's life. Their whole personality.
[00:12:33.97] But also, the physical restraint is not going to keep her quiet at night, which is a big problem with the other patients on the floor.
[00:12:40.57] [INTERPOSING VOICES]
[00:12:42.79] There isn't any--
[00:12:44.19] There's no happy medium.
[00:12:46.24] No. And she's frightened. She has nobody to turn to. It places the burden of responsibility directly on the nursing staff.
[00:13:00.62] The principle of justice holds that we should treat people fairly.
[00:13:06.59] [CHATTERING]
[00:13:12.42] We've now decided to go ahead and deliver the baby and save the mother. That will probably be done within the next hour and 15 minutes. What's our bed situation thereafter?
[00:13:24.32] Well, I'll call on the person who's on call. They're going to leave us two empty beds. And if we have a light emission, we can probably absorb the-- we can't really accommodate two more people tonight.
[00:13:37.48] In a situation such as an ICU, where you have a limited number of beds, and you have more patients than you have bed space, nurses are confronted with making a decision as to who gets a bed and who doesn't. And in that decision, they are essentially relying on the principle of justice.
[00:13:55.75] [SIRENS]
[00:13:59.81] If you have already 10 patients, and you're staffed for 10 patients, and you bring in another patient who's just as sick, and perhaps even sicker than some of the ones who've been there for a while, how are you going to spread your resources? How is that patient going to be accommodated and get the same kind of quality of care?
[00:14:28.64] OK. what I'm calling you about is Dr. Eliot's next patient. And right now, we do not have a bed.
[00:14:38.30] Frances is the charge nurse of the intensive care unit. She and her staff have to decide with physicians which patients will be admitted to their unit, discharged from their unit, transferred from their unit. Nurses know an awful lot of things about those patients. All the things that a nurse knows about a particular patient can, and perhaps inevitably do, enter into the nurse's decision about whether or not that patient should stay in the intensive care unit, or whether or not that patient should get one to one care. So the ethical question is, how do we choose fairly? Which of those factors should count?
[00:15:19.48] I try and bring in reality. I look at pregnancies. And again, that seems to be something that a nurse isn't supposed to do. But if you're here long enough, you know. Better to schedule the heart in bed six with a nurse all to herself, because the work you put into that is something that you're going to see some results with.
[00:15:51.75] When there is a bad crunch, when the staffing becomes tight, and we can't get any extra nurses, many times because there are viable patients who need the bed, and someone who is not going to live out of a unit, is in the bed right now, many times if there are no critical care beds in the hospital, there is more of a push to have those kinds of decisions made.
[00:16:25.50] We've never had the President of the United States, granted, but we've had like, a congressman's son. I'm sure it was because of the patient's status that a lot of the cooperation was engendered at 6 o'clock in the morning.
[00:16:43.45] The quality of this person's life is a really important factor. We have recognized a mindset that old people are not as valuable as young people. There's a whole bunch of ways of saying it, but it's saying that, jeez, he's had a good life. Why should we put him through all this? You put him through all this for the same reasons you put anybody through all this. It's so he can live. And if you've got five years to live, and that's what you want, you have a right to that.
[00:17:17.96] We send them out after they've had their open heart surgery, they've stabilized. But they're still not strong, really. They still need a lot of attention. There's a disagreement with the attending service about whether or not the patient goes out. For example, I think the patient should stay in. If they go out, and then that baby say, has a respiratory arrest in the middle the night, has to be intubated and brought back up again, I get mad.
[00:17:46.60] If the baby isn't ready to go out in my opinion, I'll say so. And I'll ask for the baby to stay. And someone else can go out, if that's possible. Or if not, perhaps they don't need to do that other surgery that day. That usually isn't what happens. The nurses don't have the final decision in that. But if you don't think a patient's ready to leave, you got to speak up about it.
[00:18:09.97] Because the technology is here, the question of whether this technology ought to be provided for these patients has frequently in the past not really been addressed. But now, when you're really talking about scarcity of resources, and when you're talking about cutting down health care costs, and Medicare reimbursement, et cetera, then you're really running into an area of scarcity of resources. And then, the ethical problem of, should we, which patient should we, is the question that's going to come up.
[00:18:46.11] The principal of fidelity simply means that we should be faithful to our commitments.
[00:18:52.86] I also called the family, and I told them that she was more serious, and that she had some episodes this afternoon, that they might like to come in. And the son that they were already coming in. Will you be coming soon to write anything? Do you want me to write it as a verbal order?
[00:19:11.95] Mrs. Carter is semi-conscious, and isn't able to communicate her own wishes. Although the whole health care team are convinced she is dying, they have promised her family that they will try a final 10-day experimental treatment. Is there anything you can tell me that'll make it more clear?
[00:19:34.88] Mary is torn between her promise to the family, and her commitment as a nurse to comfort her patient.
[00:19:41.52] --spontaneously comes back, but it makes me very nervous.
[00:19:47.92] They know that the situation's irreversible, and it's even more certain now tonight, after what's been happening. But she is really deteriorating, and is not going to survive. Under any circumstances, I'm convinced, and yet, I can't really sedate her at this time because of her instability. If it were decided that we would allow her to die, that support would be withdrawn, and essentially, that means allowing her to go. Then, we could give sedation. Because keeping her pressure up wouldn't any longer be an issue.
[00:20:30.66] And it's during that time that it's really comfortable, I guess, for everyone. For the nurse, especially. And of course, the patient. Because if your patient is suffering and pain, you don't want that for them. You don't want their last moments to be uncomfortable. But until a decision's been made to let them die, then you are obligated to support them as best you can, to keep their blood pressure up. And if that means withholding sedation, we do that here. I guess that's commonplace.
[00:21:07.84] That situation is just typical of what comes up where you feel like you can't really comfort. And as a nurse, that's one of the things that you're taught you're going to do for people. And that's one of your roles, is to comfort people. And not only to make them well, but also to try to make it as comfortable for them as possible. And there are times when you can't do that, and you feel like you've betrayed the patient. Betrayed their trust, perhaps. You tell patients preoperatively, you'll be given medication for pain.
[00:21:43.84] And they believe you. And it is true. But it's not really true. You don't tell the patient what really could happen. Which is that, you might become unstable and hypotensive. And we might not be able to give you anything, and you might be in a lot of pain, and all I'll be able to do is talk to you and reassure you verbally. You would never tell somebody that. You can't.
[00:22:14.07] There so much that people don't know. But at the same time, we have to honor our commitments to her family too. And it's their mother and wife that we're dealing with. The nurse is left holding the bag, I guess, so to speak. The nurse is at the bedside trying to support a patient who they know we're going to withdraw support on.
[00:22:43.55] So that's troubling. Because I still want and have to do everything possible to support her. I am both obligated to, and I want to, because of the family. At this point in time, I just want the promises that we've made to them to be kept. Why don't I just stop and say, this is enough. Then, what good would my skills be to these people?
[00:23:23.53] Often, people leave here and say they got the best care, and we feel glad that we know they got the best care they could've gotten. And that's a big reward for me as a nurse. And it's one reason I like to work, because we can give really good care to our patients.
[00:23:39.27] You can't know you're correct all the time in making these decisions. At least I can be here doing what I can within the limits of my power to make their death a little easier, or their recovery a little more pleasant, and a little speedier.
[00:23:57.04] I don't usually have people asking me these questions while this is all going on. You can't be constantly examining, how do I feel about this, or you would be diverting your attention away from the job at hand. Afterwards, I might go home and think about it. I dream about things at night. I'm sure this happens to everyone. It comes back to you. You try to not take things home with you. It's considered not healthy to do that a lot. So I try not to do that excessively. But sometimes, things come back to me in my dreams.
[00:24:36.71] [MUSIC PLAYING]
Distributor: The Fanlight Collection
Length: 26 minutes
Date: 1983
Genre: Expository
Language: English
Grade: College/Adult/Professional
Color/BW:
Closed Captioning: Available
Interactive Transcript: Available
Existing customers, please log in to view this film.
New to Docuseek? Register to request a quote.