Discussing Code Status

[FutureInternist]

Since a whole bunch of interns will be starting soon (congrats) I figured I would try to get input from those who have been through intern year already as to their way of approaching a code status discussion

Even now as an attending, I am appalled by the lack of training we get in this, the lack of laymen's terms used during these discussions and the apprehension that so many doctors seem to face when the time to discuss it comes up

I work as a hospitalist (mostly nights & purely admissions when on nights) so for me, it is important to have the pt as neatly gift wrapped as possible for the incoming rounder the next day & this (to me) involves clarifying a code status
Our census's average age is easily >60, with a LOT of >2.5SD away people as well

Below is a gist of what I say, with added bits & bobs here & there depending on the situation

Critique is MORE than welcome since I have been adjusting my words since intern year & there is always more tweaking that can be done

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So Mr Smith, unfortunately you have an infection in your lungs, called a pneumonia, and we are going to put you in the hospital for antibiotics & to check if the infection has gone into your blood or not.
Now the last thing I want to talk to you about is a bit delicate but important
Do you know what an advanced directive or living will is
(Most say no, some liken it to the POA)
Basically it is a way to make sure that you & me are on the same page, in regards to what to do, or what not to do if things go downhill
For any one in the hospital, if their heart stops beating or if their lungs stop working, we do CPR, which means we do chest compression, we shock the heart & we put a tube in their throat to help them breathe & we take them to the ICU
Is that something that you have thought about or discussed?

I do remind them that the medications, IVFs, etc they are getting, they will continue to get, so I frame it like "....you will get all the medicines & "water" etc, but if things still go bad then at that point we would stop doing anything more"

This usually prompts further Qs which helps (hopefully) to clarify the issue for them

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The # of docs I have seen asking "Do you want everything done", "Do you want us to try & save you" or some variation thereof is so high that it just boggles me that these people have not found a better way of discussing something so important

When I was a resident my goal was to have all my patients have a code status discussion documented & to remind them that anytime they are admitted, they should tell the first person they see that they are a DNR/DNI
Fell short of the goal by a WHOLE lot, , but I tried

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[FutureInternist]

While having one POA is ideal, there are usually 2 or more so I always throw in a "...we have to make sure whatever decision we make today will not cause any problems 5 years down the line"

 

[foxhound0]

Thank you for this post. As a new intern, I agree with having a detailed discussion with our elderly patients.

 

[killerleaf]

I would suggest that all of you sit down and discuss things with your family. Make sure you understand what their wishes are, and what yours are. Even if you are young and healthy, that can change in an instant. It is important for your family to know what you would want done.

 

[IJL]

Thank you for this post. As a new intern, I agree with having a detailed discussion with our elderly patients.

Code status discussions should not just be limited to elderly patients

 

[FutureInternist]

I would suggest that all of you sit down and discuss things with your family. Make sure you understand what their wishes are, and what yours are. Even if you are young and healthy, that can change in an instant. It is important for your family to know what you would want done.

Definitely
I have emails from all my immediately family that are CC'd to everyone else so everyone knows what each of us wants. This also applies to organ donation

 

[Crayola227]

First of all, at least on the order sets I've worked on, is that part of the difference between full and DNR/DNI is partial, meaning that bipap could be a rescue option, or the heart and lungs are still working but maybe they need defib.

I see everyone else leading people, leading sick people, to DNR/DNI

I tell people,

"What I'm going to talk to you about isn't because I necessarily expect this to happen, but because it's hospital policy to plan for the worst and I have to ask every single person who comes here this question. I ask people of all ages this, even myself when I come to work, because anyone could get hit by a bus. If your heart and lungs were to stop, which is technically death, would you want us to do CPR, which would be chest compressions (I do the little pantomime motion they've no doubt seen on tv)) and putting a breathing tube down your throat to use a machine to help you breathe, to try to bring you back to life?"

Almost everyone says, "if it could save me," or something like that.

I always point out, "well, most people want this so they can come back as they are. Most people want to live as close to the condition as they are now But the only issue is I can't promise if you die and we do this how close to the way you are now is how you come back. That's the risk you're taking with CPR."

Usually now they ask me what I think, or recommend. "Well, I not really supposed to say, because it's not my choice to make and I support your decision whatever it is you make. What I can say, is that in your case (now the dialogue changes depending on the paticulars of the patient) is that at your age, you have a reasonable chance of coming back the same or similar, but again, I can't promise that (to my like 45 yo w/o many comordities). There's always the chance what we bring back is not the same. Or, "in your case, I think the chances of bringing you back close to how you are now is very very low. But it's still your choice to make." Or "in your case, the chance bringing you back even at all is so low, that you might only get the harms of CPR and not any benefit."

In the case where the chance of coming back with a good outcome it low, I do say "well, there's the case where your heart is still going, but your breathing goes bad, in that case we could put you on a breathing machine, and it would buy time. In your case, the chances are ___ that we can get you off it, but there's a chance we can't." So that's addressing bipap/intubation. I recommend to almost everyone who has someone they trust to decide, that bipap is reasonable because you have to have a certain level of awakeness for that to be an option, and I hate the eldery person with pneumonia that could be treated not get bipap a few days if that could mean them getting back to good (good being baseline which might not be that good, but whatevs, it's their life, and if they've already said they don't want intubation, or that's the next serious step, if I know they and their decision maker already has a sense about that, then it seems easier to go for bipap and then "undo" it if it's not working.

The way I see it, it's almost a typical PARQ. The reality is that most patients want to live, and they don't want to be "vegetables." They just don't know what combination of procedures is most likely to do that. We don't always know that well either. The reality usually isn't that they want xyz procedure, but a certain outcome. So I try to guide them to reasonable interventions for that goal. There are those that know that they're ****ed no matter what we do, but that want it anyway. Others don't want to risk a bad outcome despite being otherwise OK. But if I think bipap could rescue and they're interested in living, I usually put that. I hate this binary thinking of full code vs DNR/DNI. There's an in between. Even really sick patients, I've rarely seen them turn down bipap if it meant we might turn it around. Intubation is a different story, and it makes sense for even really sick patients to say bipap is OK but not intubation. Some are just ready to go so they don't even want to **** with bipap if that's where it goes. I've seen people get bipap to rescue, then say no more and remove it. At least they had the chance for that much if they wanted it. I've seen sick patients go home after bipap, and I've seen families make a very fulfilling goodbye with it. With bipap you either get better or need more intervention, it's not a long-term sentence.

I'm not trying to avoid a code or decide who lives or dies. If someone wants "it all done" for like .0001% outcome of life, so be it. I also don't want people who want to live but not do a code forego bipap just because they don't want CPR, intubation, and a possible trip to vegetable land. As I see it, our job is to figure out what outcome the patient wants and what they're willing to do to get it, then try to educate them what might do that, but always let them know the most that we know that they can expect and the risks.

I get really upset about this because I feel like docs either don't explain it, or they lead it where they think the patient should go based on their own beliefs about quality of life. I want the patient to pursue the pathway they're comfortable to get what they want from life, or death as it may be.

 

[Crayola227]

And I should say I see healthy patients with the best chance of best outcome with CPR say they don't want to do it, and they never want a ventilator. So be it.\

And in the case where I know the most we're getting is a vegetable, I reassure patients that DNR/DNI status is not giving up and doing the most we can to avoid that, because I think that is a common and valid concern.

My guy with 10% EF who wants every day possible, I'm not going to deny trying to make that happen even if we get to end game and DNR/DNI is probably the best course.

 

[Crayola227]

Some places are using this video that while informative, and supported by studies that show "how much better patients understand and change to DNR after" I hate because I feel like while it's so "neutral" it's leading people, even those who stand the most to gain from CPR, to DNR. That's not my goal, to get more DNR statuses. They should understand what it is and what might/is most likely to happen and get that. That's my 2 cents anyway.

 

[FutureInternist]

The issue with patients picking & choosing which they want is that you end up doing futile care a lot of times
I've had pts want CPR for only 5 minutes, but no epi??
Or do chest compressions ONLY but no defib or intubation

We don't let pts tell us which antibx to use in a particular case so when they do ask for something that I feel is not beneficial, I tell them

I usually explain that "pumping the heart only won't help since the blood has to go to lungs to pick up oxygen & if there is no tube there to help then the blood has nothing to pick up" or something like that

As for BiPAP, I did not mention this in my original post since to me BiPAP is NOT CPR (since its not intubation)

The goal is definitely not to get more DNRs but something has to be said for avoiding doing things TO patients (rather than for them) just because one couldn't/didn't want to explain the ramifications of a particular choice.

 

[Crayola227]

The issue with patients picking & choosing which they want is that you end up doing futile care a lot of times
I've had pts want CPR for only 5 minutes, but no epi??
Or do chest compressions ONLY but no defib or intubation

We don't let pts tell us which antibx to use in a particular case so when they do ask for something that I feel is not beneficial, I tell them

I usually explain that "pumping the heart only won't help since the blood has to go to lungs to pick up oxygen & if there is no tube there to help then the blood has nothing to pick up" or something like that

As for BiPAP, I did not mention this in my original post since to me BiPAP is NOT CPR (since its not intubation)

The goal is definitely not to get more DNRs but something has to be said for avoiding doing things TO patients (rather than for them) just because one couldn't/didn't want to explain the ramifications of a particular choice.

Ah, yes, bipap is not CPR. But it is part of code discussion at least in our EHR orders for some ****ed up reason. Meaning, they're full code or no code. But there's this thing of Partial code, were you can start checking off some stuff, and I usually push for bipap because yeah, that has nothing to do with code. If they're alive, breathing, aware enough for bipap, respiratory distress, for the love of Jesus why would you not use bipap for rescue? I mean, we are trying to stabilize patients for discharge if we can, even if they have cancer, right?

I agree telling patients when stuff isn't beneficial. And your tube explanation is good too.

I agree wholeheartedly with your last statement.

I differ a little on the futile thing. Like, I want to avoid the code stuff that just gets us back a body for the ICU which will then just die, but more slowly, painfully, and expensively. So if all they want is 5 minutes of chest compressions, no tube, no epi, well, I pretty much know that's going to fail, they're dead. The chances of ROSC is so low with just that, that hell, if they get ROSC just with that it's a miracle Jesus wants them to live glad we did it I guess. (kidding).

It's futile in a way that I would actually do it. I wouldn't waste antibiotics, but if what gives you and your family peace of mind about your death is futile heroic thumping on your dead chest (that is not a full code or going to take us down the rabbit hole of vegetable land) almost like some sort of ritual to say we didn't give up, I guess. I warn people this can break ribs which can be disturbing, and that if the compressions are oxygenating the brain enough but the heart isn't beating, they may just be awake and feel the chest pounding, ribs breaking, for as long as we do compressions, and then lose consciousness and die as soon as we stop, which we will have to at some point.

I also never, unlike many residents, bring up the rib breaking thing as a factor to deter people from code, people want code because they want to live, and no body seems to bat an eyelash like somehow broken ribs are too high a price for life. I bring it up to say basically, I don't think you'll get benefit of CPR (life as we know it) but the last thing you feel might be your ribs breaking. And there's been a movement to allow family bedside during codes, so they can hear it. Could be traumatic.

I've been to the futile codes with family present, and it was actually a really really great healing thing for the family and I even think for the docs. One was a sad case a young guy too young to be dying of the cancer he was dying of. Some of those codes, we're doing our thing, the resident and staff are getting code experience, the family is huddled, crying, praying, the chaplain's there, they're crying out for Jesus, watching us sweat and toil for like 30-60 min or whatever seems like forever. And then it's done. There was something about that felt very ritualistic. It was sort of an exclamation mark to end things not just a slip away kind of thing. I think sometimes people feel comfort to have the soap opera melodrama as seen on tv dramatic medical code death of a loved one. Sometimes that's how they expect people to die, so maybe having it meet their expectations makes it easier to accept. I dunno. It was futile from a "reverse patient's death" outcome POV, but staff and family had maybe valuable experience from it. And it really doesn't take much resources to do. On the other hand, that was the first time I did compressions and his ribs audibly cracked the first time when I did it, and it was a little haunting, and I remembered so many docs talking about hard codes and stuff like that. Codes can have negative toll on morale too.

My loved one passed away in the ICU. They were full code which is how they got there, which was appropriate, but they were in very poor condition. It was a very very wonderful thing that they were in the ICU on the machines, and there was time for all of us to gather, spend time at bedside, hold hands, pray, weep, move to comfort care, and actually be with them as they took their last breath. That moment never would have happened without some amount of futile medical care at some point in my story. Probably one of the most powerful experiences of my life and one of the ones I'm most grateful for, because if someone had given up just a few hours sooner, that never would have happened that. It's not a joke but it was exactly the kind of heartbreaking death scene you would see in a movie. It's not valuable because it's like a movie. Why is that the kind of scene in a movie? Because it is a very moving and powerful way to say goodbye, no one wants to lose a loved one, but that kind of goodbye makes it into art for a reason. Not for everyone, certainly.

So I don't mean to say we do whatever patients want to make them feel good, or spend too much resources doing it, but sometimes we have to define futile and I think at end of life patient comes first, but that doesn't mean they're the only ones you're treating at a certain point. So all things being equal, I'll do 5 minutes of compression before I call it if that makes anyone feel better.

I'm going to avoid that though if I'm just going to crush this little 80 year old lady on death's door chest and just give her like 2 days to enjoy her broken ribs assuming she's even conscious.

So, to recap, in my book, dead patients I'm pretty sure will stay dead can have a few rounds of futile chest compressions if that makes anyone feel better.