Code Status Discussion

Palliative Care Editor: Victoria Trulove, MD
Reviewed by: Mohana Karlekar, MD; Sumathi Misra, MD; Steven Watson, MD; Maie El-Sourady, MD; and Matthew Peachy, MD
Section Editor: Victoria Trulove

Overview

  • Code status should be discussed at every admission and with major changes in clinical status.
    • Before discussion, ask yourself: “Why would this patient code? Is the underlying cause
      reversible? What are the chances this patient will survive to discharge after CPR? Is the
      outcome in line with the patient’s goals?”
    • A patient must have capacity to decide code status. If not, engage their surrogate.
    • Help them make an educated decision based on (1) their goals and (2) the efficacy of resuscitation. It can be helpful to share statistics on the outcomes of CPR to help them make an informed decision.
    • NEVER say “Do you want us to do everything?”
    • It is helpful to give examples of certain situations (i.e.: your heart stops or you can’t breathe because of pneumonia). After understanding their goals, it is appropriate to make recommendations based on your medical judgment.
    • A patient can be DNR but okay for intubation; the opposite (DNI but okay for resuscitation) is NOT an option as it is medically inappropriate.

An Approach to Obtaining Code Status

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.”\

Determine a Surrogate: 

  • “If you couldn’t make decisions for yourself, who would you trust to make decisions based on your wishes?”

Intubation (discuss first to avoid the ‘DNI but not DNR situation’):

  • “One of the things we discuss are ventilators (breathing machines). We use these if someone cannot breathe on their own. Some patients 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 unsure or it seems interventions may be futile (unlikely to recover to extubation), 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.”

CPR

  • Prime this with: “The next question can be difficult, but in you were to have a decline in your health, it is important to know your preferences on life support treatments such as Palliative Care. If you had a cardiac arrest, where your heart stops beating and you die, would you an attempt to restart your heart with chest compressions?”
  • If a pt seems unsure, you can offer the following: “Evidence shows 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 patient would leave the hospital.”

What if you think performing CPR is NOT medically appropriate?

  • The decision to attempt CPR is shared between a provider and the patient/family.
    • At VUMC, the patient can request an attempt at CPR, but it is ultimately the provider’s decision to offer this. The decision NOT to offer CPR must be communicated with the patient and family.
    • At the VA, it is the patient’s decision to receive CPR.
  • Revisit code status, 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 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 if she were to die, CPR would prevent a natural death.”
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