- The approach to obtaining someone’s code status should be thoughtful and pertinent to their current admission or recent change in clinical status. First ask yourself “Why would this pt code? Is resuscitation a reversible treatment in this pt’s case? What are the chances that this pt will survive to discharge following CPR? Is the anticipated outcome in line with the pt’s goals? After you have made your assessment, then make a recommendation based on both the efficacy of resuscitation and the patient’s goals. (90-year-old male with an MI may survive CPR but may wish to die a natural death. A 35-year-old with advanced cancer may be willing to endure CPR even if the chance of success is miniscule) Sometimes it is difficult to ascertain, and you can ask your attending his/her thoughts. For example, a 40 y/o pt admitted with cellulitis should probably be full code however an 83 y/o pt with class IV NYHA heart failure, CKD4 and significant frailty should probably be DNR/DNI. It is important that you are incorporating 1) the pt’s goals with 2) your understanding about the efficacy of CPR for that pt and help them come to an educated decision.
- Below are examples of phrases that can be used in framing code status. It is important to do this step wise. NEVER say “Do you want us to do everything?” This is a question very few people are okay with saying no to. It is more helpful to give examples of when these situations would arise.
Admitting a patient:
- Introduction: Normalize the conversation by stating that “these are questions we routinely ask everyone when they come into the hospital. This is a way for us to understand your wishes in the event you are unable to make your own decisions.” Otherwise, they can be caught off guard and not be able to meaningfully participate in the conversation.
- Surrogate: “If you were unable to make decisions for yourself for whatever reason, who would you trust to make your decisions? The person you pick does not have to be family but should be able to speak to your wishes and make the same choices you would make for yourself. [In a cirrhotic] For example, if you were to get confusion from your liver disease?”
- Intubation: Always do this first so you can avoid the sticky DNI but not DNR situation. Again, normalize the question. “Everyone has different opinions on what types of medical care they would want if they became sicker. One of the things we like to talk about are ventilators or breathing machines. Some tell us to try a breathing machine for a trial, but they would not want to be kept alive on a ventilator.” Now make a recommendation. “In your case I think if you were to need a ventilator, based on your health I think it would [work, not work,]” Pause and allow them to ask questions. Also remember that if they say DNI, then they must be DNR because intubation occurs with ACLS (this is not allowed at VUMC but is at the VA… I don’t recommend getting in this situation).
- CPR: Prime this question with “The next question I have to ask you can be hard to think about, but it is important that we know what you would want. In the event you had a cardiac arrest, that is, when your heart stops beating, which would mean you died? This is different from a heart attack. [pause]. We know based on the evidence that CPR is not always successful. It really depends on the situation. In your case, I think CPR would be (make a recommendation here). Knowing this, would you want us to attempt CPR or try to resuscitate you?”
What if you don’t agree with your patient’s decision…
- At the end of the day, it is their decision (attendings may change the code status out of medical futility in Tennessee).
- If you think the pt didn’t understand, or was overwhelmed, or the clinical situation has changed, you may want to go back and revisit the conversation, perhaps with another family or friend present. Some pts have seen CPR on a loved one and seen it be successful and others have only seen it on TV. These experiences greatly influence their decision.
- Consider framing the discussion differently and offer your recommendation: “While you are in the hospital, we will support you with interventions and medications that we think are helpful based on what you have told us important to you. However, we are worried that some of the interventions you are asking for may do more harm than good. Many people think that CPR works like it does on TV. Unfortunately, we know that the vast majority of patients who need CPR in the hospital do not survive like they do on TV. In your case, we do not think it would bring you back to your current state. I worry that this is not something that will be helpful to you.”
- Sometimes it can be more of a discussion after a patient says “Yes I would want CPR” you can respond “I understand and respect your choice… maybe we can talk more about this later, in particular if your health changes.”
- Worried they may not understand CPR? Note that it is important to share at the beginning of the conversation otherwise the patient may feel like you are trying to coerce them into a decision. “Can I share some numbers about how often CPR can help?” Sometimes using fingers to show these numbers helps. “If you take 10 people in this hospital and all of their hearts stop beating, which would mean they have died, and we get to them as fast as possible, only 3 of them would have their hearts restarted and only 1 of them would ever leave the hospital.”
- Another phrase that is helpful (and when the discussion occurs with surrogates leads to higher rates of changing code status than saying DNR): “allow for a natural death”. For example, “I worry that given how sick your [loved one] is, that the additional interventions of CPR if she were to die, would prevent her from having a natural death”