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 Tips for when families or patients insist on inappropriate code status, the plan of care of medical interventions in the event of respiratory or cardiac arrest.

Code status refers to the plan of care of medical interventions in the event of a patient’s respiratory or cardiac arrest. ‘Full code’ implies the use of all available measures to save the patient’s life, whereas ‘no code’ or DNR status implies allowing a natural death without non-comfort related interventions. In between are ‘variant code’ statuses, which would enable some interventions but not others. For instance, a patient may accept intubation in case of a respiratory arrest but not chest compressions for cardiac arrest.

Near the end of life, families, caregivers, and patients may deal with significant stress and conflict, leading to disagreements among themselves and the care team regarding code status. These issues must be discussed frankly and sympathetically with decision-makers, with full respect for principles of patient autonomy and shared decision-making. I will share a few generally applicable approaches to this situation.

1. Know with whom you are speaking. Many patients have advanced directives (AD) that determine who is authorized to make medical decisions should they become incapacitated. Some families may not know if an AD has been established, and the AD may not be available on the EHR. The importance of establishing AD prior to critical illness or significant surgery is clear.
2. Early palliative consultation aids in determining these matters by helping families and patients understand the issues involved while giving the care team insight into their concerns.
3. Don’t hide the trauma (and poor outcomes) involved with CPR efforts. Patients/families need to know that with the modern emphasis on fast, deep chest compressions, even a successful resuscitation will likely lead to multiple fractured ribs and perhaps sternum—likely leaving the patient with considerable pain. Similarly, the statically poor outcomes of in-hospital cardiac arrest—both for survival and neurologic recovery—should be shared.
4. Chaplains should not be involved in these issues unless requested by families or patients. Some may feel affronted by attempts at spiritual guidance or support, whereas others see benefit. This question needs to be handled with considerable sensitivity.
5. Organ donation should never be discussed unless specifically requested by families. In this case, questions should be answered as truthfully and respectfully as possible, understanding that the primary duty of the care team is to the patient’s well-being.
6. I generally discourage ‘variant code’ status but accept them in certain circumstances out of respect for the patient’s autonomy. I do not offer illogical and injurious code statuses, such as ‘perform shocks and CPR but no intubation.’
7. On rare occasions, it must be emphasized that the care team is not obligated to participate in futile/injurious care. In these situations, formal involvement of ethics committees is useful. They serve as the Hospital’s official response to the dilemma and indicate the seriousness and gravity to which the Hospital holds the matter.
8. Involving the patient’s primary physician or, in some cases, specialists, may help resolve questions regarding the patient’s course and likely prognosis.
9. Occasionally, physicians encounter patients who wish no life support interventions, even if their prognosis might otherwise be acceptable. It is best to counsel these patients thoroughly about their desires, particularly before going into surgery. Hospitals may have policies suspending a DNR status around surgeries or other interventions, and the affected patient should be aware of these policies.
10. Significant issues or changes in code status should be documented in the medical record to ensure legal compliance and care continuity.
11. Families with certain cultural or religious beliefs and/or limited English proficiency may or may not require additional support and education and, of course, professional translation services.

Based on these and other principles, it is hoped that these discussions will lead to improved care at the end-of-life, consistent with the patient’s wishes and ethical standards.