Code status discussion

[cbrons]

Anyone have a better script to discussing this with patients that should definitely be DNAR? The script: "Would you want us to do everything we can to bring you back" is pretty dumb and gives patient's a false impression.

---

Members don't see this ad.

 

[Raryn]

I have to ask you one more question that I ask every patient admitted to the hospital.

Lets say that, God forbid, while you are here you are in a situation where your heart stops beating and you lose your pulse. In that one situation, what would be your wishes? Would you prefer to receive chest compressions, electric shocks, and medication, or would you prefer that we allow you to die naturally?

Your answer doesn't have any other influence except in the one situation that your heart is not beating.

 

[NotAProgDirector]

My script is this (it's long, I know. But there's no way to do this well and be brief):

[Although unlikely to happen] OR [Due to your / your loved one's severe illness], one topic we need to discuss is what to do if you/they suddenly have a life threatening event, such as your heart stops beating, or you are having trouble breathing on your own. We need to review that now, because should it happen someone will need to make a quick decision about what to do and may not have time to contact family or you may be too ill to discuss it yourself. You may have completed a form designating someone else to make decisions for you, but since you are awake and alert, it's important that I and your family know what's important to you.

If something very severe like this were to occur, there are several options about what we could do. One option is to treat you as aggressively as possible using medications, machines, and procedures to try to save your life. This might require using a breathing machine to help you breath, and trying to get your heart started with electrical shocks should it stop. If this happens, you will likely be unconscious either from your severe illness, or from medications we need to give you. You would likely be in an ICU for an extended period of time. Although some people can make a full recovery from a serious problem like this, many never fully recover -- some brain damage can happen, and a long hospital stay can make you very weak. Some patients survive, but are unable to go back home because of their illness. But some recover well and can have a good life.

The other option is to focus on comfort care. Should you become suddenly ill like this, instead of using machines and procedures to try to save your life we focus on making sure you are comfortable, using pain medications, relaxing medications, or anything else we think would maximize your comfort. We would treat you aggressively and fully for everything else -- just focus on comfort if it appeared that something very acute and serious was happening.

A third, middle option is to try "heroic" measures for a short period of time. If we can turn things around quickly and it appears you'll make a good recovery, then that's great. If it looks like something terrible has happened and that it will impact your life going forward, we would then focus on comfort. A reasonable amount of time to consider would be 48-72 hours.

There is no right answer here -- each person has their own desires and needs. Some people reach a stage of life where they feel they have enjoyed their life, want to continue if the quality of life is good, but should something catastrophic happen, would want to pass away comfortably. Other people feel that fighting for every day of life is important, or have some future event that they really want to be present for. No decision you make is permanent -- you can change your mind any time. Have you talked about these types of decisions with your PCP or loved ones? What's important to you?

 

[cbrons]

My script is this (it's long, I know. But there's no way to do this well and be brief):

[Although unlikely to happen] OR [Due to your / your loved one's severe illness], one topic we need to discuss is what to do if you/they suddenly have a life threatening event, such as your heart stops beating, or you are having trouble breathing on your own. We need to review that now, because should it happen someone will need to make a quick decision about what to do and may not have time to contact family or you may be too ill to discuss it yourself. You may have completed a form designating someone else to make decisions for you, but since you are awake and alert, it's important that I and your family know what's important to you.

If something very severe like this were to occur, there are several options about what we could do. One option is to treat you as aggressively as possible using medications, machines, and procedures to try to save your life. This might require using a breathing machine to help you breath, and trying to get your heart started with electrical shocks should it stop. If this happens, you will likely be unconscious either from your severe illness, or from medications we need to give you. You would likely be in an ICU for an extended period of time. Although some people can make a full recovery from a serious problem like this, many never fully recover -- some brain damage can happen, and a long hospital stay can make you very weak. Some patients survive, but are unable to go back home because of their illness. But some recover well and can have a good life.

The other option is to focus on comfort care. Should you become suddenly ill like this, instead of using machines and procedures to try to save your life we focus on making sure you are comfortable, using pain medications, relaxing medications, or anything else we think would maximize your comfort. We would treat you aggressively and fully for everything else -- just focus on comfort if it appeared that something very acute and serious was happening.

A third, middle option is to try "heroic" measures for a short period of time. If we can turn things around quickly and it appears you'll make a good recovery, then that's great. If it looks like something terrible has happened and that it will impact your life going forward, we would then focus on comfort. A reasonable amount of time to consider would be 48-72 hours.

There is no right answer here -- each person has their own desires and needs. Some people reach a stage of life where they feel they have enjoyed their life, want to continue if the quality of life is good, but should something catastrophic happen, would want to pass away comfortably. Other people feel that fighting for every day of life is important, or have some future event that they really want to be present for. No decision you make is permanent -- you can change your mind any time. Have you talked about these types of decisions with your PCP or loved ones? What's important to you?

This is excellent
My only problem with this is the last line.. "have some future event they want to be present for"... i think that can give the wrong impression that really old or really sick patients can actually be able to stand up in a wedding in the future when the reality is that the best they can reasonably hope for is to be on a feeding tube in a wheel chair without any comprehension of whats going on

 

[URHere]

I try to make it clear that a code is how we respond when someone has already technically died. My script is something like this:

"I have one more question that I have to ask of every single person who comes to the hospital.

I don't expect anything bad to happen to you while you're here, but if something were to happen to you: if your heart stopped beating, if you stopped breathing, and you died, I need to know how aggressive you would want us to be in trying to bring you back to life.

The most aggressive option is called "full code", and it usually means chest compressions (which break ribs), shock paddles, and a breathing tube down your throat. (At this point, patients often have questions about life support, chances of recovery, etc and I pause to answer their questions).

Another option is to not do compressions, shocks, or a breathing tube and to just make you comfortable as possible if your heart were to stop beating. This doesn't mean that we won't do absolutely everything possible for you up until that point. We'll still talk to you about blood products, antibiotics, and medications to help your heart beat more strongly if you need them. You and your family will still be involved in making decisions about your care every step of the way.

Again, I don't expect anything bad to happen to you while you're here, but I need to know that if something unexpected happens that we can give you the kind of treatment that you want"

Note: If someone is critically ill or tenuous, I'll cut out the "I don't expect anything bad to happen to you" part and I'll make it clear that there is a very good chance of things getting worse, which could lead to a code situation.

 

[PTPoeny]

I try to make it clear that a code is how we respond when someone has already technically died. My script is something like this:

"I have one more question that I have to ask of every single person who comes to the hospital.

I don't expect anything bad to happen to you while you're here, but if something were to happen to you: if your heart stopped beating, if you stopped breathing, and you died, I need to know how aggressive you would want us to be in trying to bring you back to life.

The most aggressive option is called "full code", and it usually means chest compressions (which break ribs), shock paddles, and a breathing tube down your throat. (At this point, patients often have questions about life support, chances of recovery, etc and I pause to answer their questions).

Another option is to not do compressions, shocks, or a breathing tube and to just make you comfortable as possible if your heart were to stop beating. This doesn't mean that we won't do absolutely everything possible for you up until that point. We'll still talk to you about blood products, antibiotics, and medications to help your heart beat more strongly if you need them. You and your family will still be involved in making decisions about your care every step of the way.

Again, I don't expect anything bad to happen to you while you're here, but I need to know that if something unexpected happens that we can give you the kind of treatment that you want"

Note: If someone is critically ill or tenuous, I'll cut out the "I don't expect anything bad to happen to you" part and I'll make it clear that there is a very good chance of things getting worse, which could lead to a code situation.

I think you have a great script. I definitely find it helpful to explain how forceful CPR is, including the fact that it breaks ribs. Depending on the family I have also offered a code status where we will plan to do CPR for long enough to send a single iSTAT and see if there is something fixable, usually we talk about this in kids who have a history of severe electrolyte abnormalities. I also think it is important to explain like you do above that the DNR/DNI option still includes all medical treatments other than CPR/shocks/ETT including surgeries, heart medications, antibiotics. I specifically don't talk about comfort care unless we are discussing limiting all treatments and not just talking about code status. I also like to reassure parents that I have taken care of kids who have been DNR for 15 years and just never had that sudden event, it was just that their parents knew it was a risk because of his medical conditions and wanted to be sure doctors never did CPR.

 

[FutureInternist]

Discussing Code Status

 

[AdmiralChz]

Every physician should be comfortable having the "code status" discussion and elucidating what exactly the patient desires, and of course documenting appropriately.

We run into this all the time in anesthesiology, and my policy has been to honor their requests as best we can. Usually we can't avoid intubation but we certainly don't have to perform ACLS measures if they go into some non perfusing rhythm. I've had surgeons cancel cases where the patient wanted nothing done as the surgery was simply too risky, that's on them.

Anyways, there are many websites and some good advice above. Please don't fall into the trap of "well, you're having surgery so we need to suspend your DNR for 24 hours" or, worse, 30 days. It's lazy and not patient-centric. If the patient really has that high of a mortality risk should you be doing the case at all?

 

[organdonor]

"Not that I think anything like this is going to happen, but I have to ask every patient this. In the rare event that while you are here your heart stops beating, would you want us to do everything to bring you back? That would include things like electric shocks to your chest, a tube down your throat and a machine to breath for you, CPR where we press hard and fast on your chest often so hard we break ribs, and medicines to artificially support your blood pressure? To maximize the chance of any of these working they are often done together"

without the first qualifier as an intern my patients always got needlessly worried. I try to give all the supportive measures as a package. Now if someone truly wants some components and not others I will have that discussion but I've been in too many "partial codes" that were just awful. "new intern what do you mean they are +meds +intubation +compressions but no defibrillation?!" "well that is what they chose when I admitted them Organdonor" Thank god Epic added all those nice little click boxes (hard eyeroll).

 

[Apollyon]

"Not that I think anything like this is going to happen, but I have to ask every patient this. In the rare event that while you are here your heart stops beating, would you want us to do everything to bring you back? That would include things like electric shocks to your chest, a tube down your throat and a machine to breath for you, CPR where we press hard and fast on your chest often so hard we break ribs, and medicines to artificially support your blood pressure? To maximize the chance of any of these working they are often done together"

without the first qualifier as an intern my patients always got needlessly worried. I try to give all the supportive measures as a package. Now if someone truly wants some components and not others I will have that discussion but I've been in too many "partial codes" that were just awful. "new intern what do you mean they are +meds +intubation +compressions but no defibrillation?!" "well that is what they chose when I admitted them Organdonor" Thank god Epic added all those nice little click boxes (hard eyeroll).

Several years ago, here on SDN, I posted something quite similar, and had one ******* poster go up one side me and down the other about how wrong I was, yet assiduously avoided providing an alternate terminology, even when asked multiple times. That's SDN for ya.

In any case, that's how I steer the conversation - I paint the (true) barbaric picture of how a code goes.

 

[dpmd]

Every physician should be comfortable having the "code status" discussion and elucidating what exactly the patient desires, and of course documenting appropriately.

We run into this all the time in anesthesiology, and my policy has been to honor their requests as best we can. Usually we can't avoid intubation but we certainly don't have to perform ACLS measures if they go into some non perfusing rhythm. I've had surgeons cancel cases where the patient wanted nothing done as the surgery was simply too risky, that's on them.

Anyways, there are many websites and some good advice above. Please don't fall into the trap of "well, you're having surgery so we need to suspend your DNR for 24 hours" or, worse, 30 days. It's lazy and not patient-centric. If the patient really has that high of a mortality risk should you be doing the case at all?

In my state it is actually unlawful to force the patient to suspend their DNR. A discussion is required regarding their wishes, though the involved physicians are then allowed to decline to participate in the procedure if the patient chooses an option they disagree with. Sometimes the procedure is being offered as there will be certain death without that is likely to be painful. In that case I actually prefer to have the DNR in place since if their overall condition was such that they decided they didn't want CPR it isn't like the fact they code on an OR table means they are magically going to have a better outcome than they otherwise would. So why not just comply with their wishes. Obviously the DNI part is usually going to be a deal breaker, but I find that if we discuss in advance a time frame for removing the tube that they patient and family will be satisfied. Sometimes I get an anesthesiologist who won't go along with it unless they DNR is suspended for a period of time. In that case I discuss with the patient that I can either try to find a different anesthesiologist (but may not be possible and would certainly add time that would worsen their likelihood of recovery) or we can suspend for the surgery and I will reinstitute it right after their procedure. Most of the time I don't think they are going to code on the table otherwise I would be more likely to recommend hospice instead of attempting the operation, and the anesthetic eliminates some of the issues most people have with the idea of CPR. But once the surgery is complete I am not going to continue to subject the patient to the whims of the anesthesiologist.

 

[AdmiralChz]

In my state it is actually unlawful to force the patient to suspend their DNR. A discussion is required regarding their wishes, though the involved physicians are then allowed to decline to participate in the procedure if the patient chooses an option they disagree with. Sometimes the procedure is being offered as there will be certain death without that is likely to be painful. In that case I actually prefer to have the DNR in place since if their overall condition was such that they decided they didn't want CPR it isn't like the fact they code on an OR table means they are magically going to have a better outcome than they otherwise would. So why not just comply with their wishes. Obviously the DNI part is usually going to be a deal breaker, but I find that if we discuss in advance a time frame for removing the tube that they patient and family will be satisfied. Sometimes I get an anesthesiologist who won't go along with it unless they DNR is suspended for a period of time. In that case I discuss with the patient that I can either try to find a different anesthesiologist (but may not be possible and would certainly add time that would worsen their likelihood of recovery) or we can suspend for the surgery and I will reinstitute it right after their procedure. Most of the time I don't think they are going to code on the table otherwise I would be more likely to recommend hospice instead of attempting the operation, and the anesthetic eliminates some of the issues most people have with the idea of CPR. But once the surgery is complete I am not going to continue to subject the patient to the whims of the anesthesiologist.

Oy, a lot in this post... I hope you don't go anesthesiologist shopping so you can do your cases. We don't do much to our "whims" more just try to provide the best care for a patient.

Yes, the surgeons hate hearing I won't be shocking V Tach if it happens during their ex lap of an 89 year old demented bowl perf, but honestly it's what's best for the patient and maybe the surgery shouldn't be taking place in the first place. That's a true story from last week, we canceled the case and the family was totally on board with the decision. Surgeon eventually understood and agreed, he hadn't been explained the severe comorbidities prior.

 

[dpmd]

Oy, a lot in this post... I hope you don't go anesthesiologist shopping so you can do your cases. We don't do much to our "whims" more just try to provide the best care for a patient.

Yes, the surgeons hate hearing I won't be shocking V Tach if it happens during their ex lap of an 89 year old demented bowl perf, but honestly it's what's best for the patient and maybe the surgery shouldn't be taking place in the first place. That's a true story from last week, we canceled the case and the family was totally on board with the decision. Surgeon eventually understood and agreed, he hadn't been explained the severe comorbidities prior.

I don't mind the anesthesiologist saying they don't want to do the case. I mind if they are ok with doing it but insist upon the patient remaining full code for x amount of time after the case. I will compromise by letting them run a code on the table if the worst happens intraop (but would be perfectly fine allowing natural death as per the patient's initial wishes) as long as the patient is ok with it, but I see no reason to continue that into the ICU if the patient doesn't want it. That is why I called it their whim. This is a different situation than the patient or family that has not received appropriate counseling for their condition. I have declined to operate on some bowel perfs and high grade obstructions (usually malignant) whose overall condition made comfort care more appropriate. But on occasion there is a high risk patient that knows they are high risk and doesn't want heroics but is still interested in the chance of improvement surgery might offer. In that case I think the best care of the patient would be to give them that chance if appropriate but respect the patient wishes if the heart stops. I suppose if the heart stops for an incredibly reversible reason that would be different, but how often is that the case?

 

[AdmiralChz]

I don't mind the anesthesiologist saying they don't want to do the case. I mind if they are ok with doing it but insist upon the patient remaining full code for x amount of time after the case. I will compromise by letting them run a code on the table if the worst happens intraop (but would be perfectly fine allowing natural death as per the patient's initial wishes) as long as the patient is ok with it, but I see no reason to continue that into the ICU if the patient doesn't want it. That is why I called it their whim. This is a different situation than the patient or family that has not received appropriate counseling for their condition. I have declined to operate on some bowel perfs and high grade obstructions (usually malignant) whose overall condition made comfort care more appropriate. But on occasion there is a high risk patient that knows they are high risk and doesn't want heroics but is still interested in the chance of improvement surgery might offer. In that case I think the best care of the patient would be to give them that chance if appropriate but respect the patient wishes if the heart stops. I suppose if the heart stops for an incredibly reversible reason that would be different, but how often is that the case?

Ah, I think we are arguing the same thing only your experience was driven by the Anesthesiology and mine was driven by Surgery.

 

[dpmd]

Ah, I think we are arguing the same thing only your experience was driven by the Anesthesiology and mine was driven by Surgery.

Yeah. Just so you know I would call it a whim of the surgeon if they wanted to force the DNR pt to suspend it for some random period of time.

 

[Smurfette]

I've worked in multiple institutions where it is written policy to suspend the DNR for 24 hrs in order to take the patient to surgery.
In reality, I've told patient/family that we'll use our judgment if something should happen intraop as to whether to resuscitate these patients (and anesthesia always agrees with this), but the nursing staff will repeat the "24 hr suspension policy" to the patient/family ad nauseum and during the time out...

I also make sure to tell the ICU immediately post op that the patient's DNR status is back active but they need an order to override hospital policy despite the DNR status listed on the EMR patient banner.

 

[dpmd]

I've worked in multiple institutions where it is written policy to suspend the DNR for 24 hrs in order to take the patient to surgery.
In reality, I've told patient/family that we'll use our judgment if something should happen intraop as to whether to resuscitate these patients (and anesthesia always agrees with this), but the nursing staff will repeat the "24 hr suspension policy" to the patient/family ad nauseum and during the time out...

I also make sure to tell the ICU immediately post op that the patient's DNR status is back active but they need an order to override hospital policy despite the DNR status listed on the EMR patient banner.

This is why i am glad my state addressed this. It is a silly policy.

 

[Smurfette]

This is why i am glad my state addressed this. It is a silly policy.

I agree. Just wanted to point out that it's not necessarily at the whim of a surgeon.

 

[dpmd]

I think one interesting question surrounding the suspension of a DNR is - how long to suspend it for? I've seen a variety of things describe 24 hours as the standard, but I hardly think that covers the whole "perioperative" period.

We actually had a case where this came up a couple of years ago - older patient, relatively high risk, but a completely elective surgery. He had a DNR in place and after careful discussion with the attending agreed to move forward with surgery and suspend the DNR.

Well on like POD4 or something they had respiratory distress and a code was called. Medicine team runs codes on the floor; surgery intern will help when they arrive but the chief is at home. In this case the code team didnt' want to intubate/code the guy because of the pre-existing DNR. Finally the chief at home got called; tried to explain the situation but ultimately was like "just f*****ng tube him!". Obviously not the chillest way to handle it but they finally did.

Patient turned out to have been fluid overloaded; got extubated like 24 hours later after some diuresis and went home.

If the patient wants to suspend for whatever period of time, I have no issue with it. But we get dinged for any death within 30 days of surgery so if the goal is to ensure that perioperative issues aren't the cause then you really ought to be suspending it at least that long. But if the patient doesn't want that then what is magical about 24 hrs versus one hour postop. Either way they aren't on the table which I suppose is one goal people have in regard to when the patient dies (isn't on on table death more paperwork for someone?)