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Code Status Discussion

Katie Sunthankar

  • The approach to obtaining someone’s code status should be thoughtful and pertinent to their current admission or recent change in clinical status
    • 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, help pt make an educated decision based on both the efficacy of resuscitation and the pt’s goals
  • Below are examples of phrases that can be used in framing code status.
    • NEVER say “Do you want us to do everything?” Most pts will respond yes to this even if they do not want CPR
    • It is more helpful to give examples of when these situations would arise and make recommendations based on your medical judgment factoring in pt's goals

Admitting a pt:

  • Introduction: Normalize the conversation by stating, “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.”
  • Surrogate: “If you were unable to make decisions for yourself, who would you trust to make your decisions? The person you pick should be able to speak to your wishes and make the same choices you would make for yourself.”
  • 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, 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. It is technically allowed at the VA if the pt specifically requests but would not recommend routinely providing this option)
  • 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 an emergency. Specifically, if you had a cardiac arrest where your heart stops beating and you die, would you want chest compressions to try and restart your heart? 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 to resuscitate you?”
    • A helpful way to share data about the success of CPR: “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.”

## What if you do not think performing CPR Is medically appropriate?… - At the end of the day, it is their decision (attendings may change the code status out of medical futility in Tennessee) - Code status can be revisited throughout the hospital stay, especially if the pt was initially overwhelmed or if their clinical status evolves. Sometimes pts find it helpful to have a family member or friend present. - 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 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.” - 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”