Code Status Discussion

Palliative Care Editor: AJ Winer, MD
Reviewed by Mohana Karlekar, MD
Section Editor: AJ Winer, MD

Overview

  • Approaching a code status should be thoughtful. It should also be pertinent to a pt’s current admission or a recent change in clinical status
    • Ask: “Why would this pt code? Is resuscitation a reversible treatment in this case? What are the chances this pt will survive to discharge after CPR? Is the outcome in line with the pt’s goals?"
    • Help the pt make an educated decision based on (1) their goals and (2) the efficacy of resuscitation.
  • Important points to keep in mind for code status discussions:
    • A pt must have decisional capacity to decide their code status. If not, engage their surrogate
    • NEVER say “Do you want us to do everything?” Many pts say yes, even if they do not want CPR
    • It is helpful to give examples of certain situations (i.e.: your heart stops or you can’t breathe because of a bad pneumonia). After understanding a pt’s goals, it is appropriate to make recommendations based on your medical judgment.
    • NOTE: A pt can be DNR but okay for intubation (i.e. no CPR in the case of cardiac arrest; however, if the pt develops respiratory failure, they would want intubation)
    • The opposite (DNI but okay for resuscitation) is NOT an option at VUMC, as we intubate in ACLS
    • Every new pt to your service (admission or transfer) needs code status updated
    • For pts you worry may decompensate, consider confirming/readdressing code status

An Approach to Obtaining Code Status

  • Introduction:
    • Normalize the conversation- “These are questions we ask every pt when they come to the hospital. We don’t expect this to happen, but it is important for us to understand your wishes in the event you are unable to make your own decisions.”
  • Determining a Surrogate:
    • “If you couldn’t make decisions for yourself, who would you trust to make your decisions? The person you pick should be able to speak to what they think you would want, NOT what they would want for you.”
  • Intubation (discuss this first to avoid the ‘DNI but not DNR situation’):
    • “Everyone has different opinions on what type of medical care they would want if they became sicker. One of the things we discuss are ventilators (breathing machines). We sometimes use these if someone cannot breathe on their own (i.e. pneumonia). Some pts want to trial a breathing machine for a short time to see if they improve. But they would not want to be kept alive on a ventilator. Do you know what you might want?"
    • If they are not sure, or it seems interventions might be futile (i.e. pt has severe frailty or end-stage disease that makes recovery to extubation unlikely, you can make a recommendation: “In your case, if you were to need a ventilator, I think this would be reasonable to trial" or "I worry you might not be able to recover enough to breathe on your own.” Pause and allow for questions.
    • Remember if they say DNI, they must be DNR because intubation occurs with ACLS. This is not allowed at VUMC. It is technically allowed at the VA if the pt specifically requests it.
  • CPR:
    • Prime this with: “The next question can be hard to think about, but in case of an emergency, it is important to know what you would want. If you had a cardiac arrest, where your heart stops beating and you die, would you want chest compressions to try to restart your heart?”
    • If a pt seems unsure, you can offer the following: “Evidence that CPR is not always successful. If you take 10 pts and their hearts stop, meaning they died, and we do CPR as fast as possible, only 3 of them would have their hearts restarted. Only 1 pt would leave the hospital.”

What if you think performing CPR is NOT medically appropriate?

  • It is a pt’s decision (attendings can change code status out of medical futility in TN at VUMC not at the VA)
  • Code status can be revisited, especially if the pt was initially overwhelmed or if their clinical status changes.
  • 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 cause more harm than good. Many people think that CPR works like it does on TV. Unfortunately, we know that most pts 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 and would cause you to suffer.”
  • Another phrase that is helpful is “Allow for a natural death.” When the discussion occurs with surrogates, this leads to higher rates of changing code status than saying DNR. 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.”
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