Discussing Code Status

[FutureInternist]

Since a whole bunch of interns just started (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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[deleted480308]

“Last couple questions. I hope it never comes to this but in case it does I have to ask you the same question I ask literally everyone who come here. If your heart stops working and we think the only shot we have to maybe get it working right is to have a bunch of people run in here and push on your chest very hard while we get a machine ready to try and shock your heart back into working, we call that cpr, is that what you want us to do? Or would you prefer to let nature take it’s course and be allowed to die without having to go through that? (Answers)
I can honor your wishes there, next question, if start having enough trouble breathing that I think you will die if I don’t put a tube in your throat and force air into your lungs with a machine, do you want me to come in and put that that tube down your throat or would you prefer me to not put you through that and let you die naturally without having to go through that? (Answers) “

 

[FutureInternist]

“Last couple questions. I hope it never comes to this but in case it does I have to ask you the same question I ask literally everyone who come here. If your heart stops working and we think the only shot we have to maybe get it working right is to have a bunch of people run in here and push on your chest very hard while we get a machine ready to try and shock your heart back into working, we call that cpr, is that what you want us to do? Or would you prefer to let nature take it’s course and be allowed to die without having to go through that? (Answers)
I can honor your wishes there, next question, if start having enough trouble breathing that I think you will die if I don’t put a tube in your throat and force air into your lungs with a machine, do you want me to come in and put that that tube down your throat or would you prefer me to not put you through that and let you die naturally without having to go through that? (Answers) “

I like the “I ask everyone this question..” part ‘cos sometimes the 90 yo is in for a very minor issue but I just use that admit as a way to get them to address it.

If they feel its a minor issue they may not want to address it.

Will add 🙂

 

[WheezyBaby]

I think a lot of people (myself included) early in training approach the code conversation from a point of fear "Please make yourself DNR so I don't have to code you and fail," and regardless of how it's phrased, I think that underlying feeling is often captured by the patient or their family. It should be approached from the point of what's truly in the patient's best interest, specifically whether a code would be in line with achieving their goals of care (I think we all recognize this, but really internalizing it is another thing). If I really want to have a meaningful code discussion (and it's not for someone who is essentially peri-arrest so there's some time), I'll ask them things to tease out what it is that makes life worth living for them. I'll segue from that to providing information about what a code involves and what outcomes they might expect from that. I don't paint death as the bad outcome so much as I try to paint an accurate picture of what their expected survival chance is, then go on to describe what surviving a code might look like (particularly with regard to anoxic brain injury, pain related to rib fractures, likelihood of ever returning home vs remaining life in ECF, etc). I generally offer what I think I would want for myself if I was in the patient's position, and then offer a recommendation for what I think should be done based on how their values align (or not) with going through a code. Some people for better or worse rigidly value longevity over everything (or at least refuse to voice anything but this), in which case, fine, it really doesn't effect me to attempt a resuscitation for 10 minutes,

 

[FutureInternist]

Thats a good take.
I don’t run codes so it’s usually not a big deal to me if they remain full code, but I do try to make sure that whatever decision they make, they have the info.

I am surprised by how many docs seems to shy away from “recommendations” when its literally a life or death issue.

If, in my opinion, a patient shouldn’t be full code (eg metastatic cancer with palliative radiation), then I am just as forceful on that as I would be if a patient asked me for antibiotics for a viral infxn, but unfortunately in the end, in the US, it is a patient decision rather than a medical one

 

[leviathan]

but unfortunately in the end, in the US, it is a patient decision rather than a medical one

Can you provide me with laws or lawsuits + case precedent to back this up? It's definitely the culture in the US, but I'm not aware of any laws saying you do or don't have to provide care you feel is inappropriate.

In Canada it's decided at the level of the provinces. Some provinces are clear that you don't have to offer care that you feel is futile, whether that be CPR, or dialysis, down to an antibiotic for a viral infection. Other provinces don't provide any guidance at all. At the supreme court level they unfortunately have made the distinction that you can refuse to provide an intervention, but once it's being given (e.g. ventilation), you can't withdraw it without consent.

 

[FutureInternist]

Just one out of many like this

Jahi McMath case - Wikipedia

en.m.wikipedia.org

A single doc does have option to take themselves off the case if they feel they are providing futile care, but in this case the whole hospital was basically forces to provide care to someone they thought was futile.

 

[WheezyBaby]

In general, I don't feel the medicolegal environment in the states facilitates the concept of futile care outside of extreme cases, e.g. clinical brain death. I think many would consider doing a resusc on a rotaproned 60 yo with a high pressor requirement who arrests futile care. But are you going to exposure yourself to the medicolegal risk of not doing a resusc when the alternative is do it for 10 minutes and be done with it?

 

[FutureInternist]

In general, I don't feel the medicolegal environment in the states facilitates the concept of futile care outside of extreme cases, e.g. clinical brain death. I think many would consider doing a resusc on a rotaproned 60 yo with a high pressor requirement who arrests futile care. But are you going to exposure yourself to the medicolegal risk of not doing a resusc when the alternative is do it for 10 minutes and be done with it?

To me, that is still torturing the patient, although I am way more flexible if pt is choosing it for themselves.

It is when their POA chooses a course that is either futile, or worse, directly contradictory with pt’s wishes, that I get my undies in a twist.

 

[WheezyBaby]

Ive only been a part of a couple arrests where I think the patient regained a meaningful degree of consciousness from compressions and those were ones who actually had a meaningful shot of recovery following ROSC. My bigger moral injury is the worry they actually "beat the odds" and achieve ROSC. I agree with you about your latter point and would be inclined to be quite directive there and potentially involve ethics

 

[FutureInternist]

Ive only been a part of a couple arrests where I think the patient regained a meaningful degree of consciousness from compressions and those were ones who actually had a meaningful shot of recovery following ROSC. My bigger moral injury is the worry they actually "beat the odds" and achieve ROSC. I agree with you about your latter point and would be inclined to be quite directive their and potentially involve ethics

True....the fear isn’t that they’ll die, its that they “survive”.

I always tell pts theres a difference b/w living and “being alive”.

Worst come to worst, just get the 4’5” nurse to do “chest compressions” 😉

 

[akinetopsia]

This was a good video I found elsewhere. You don't have to put in any information, you can just watch the video on the website.

Code Status Video

This video was developed for use with patients when explaining code status. If you would like a copy of the video for use at your institution, please complete the form below. An MP4 file to...

www.mmcgmeservices.org

 

[FutureInternist]

Good video.
Thanks

 

[j4pac]

Patients often don’t know the difference between a living will and code status. And that often leads to patients not understanding their options and confusing one for the other if you are rushing through and/or not explaining what code status actually means.

 

[Crayola227]

@WheezyBaby addressed this much better in this thread than I've seen done in the past.

As far as making recommendations, I agree that it isn't really for the physician to "recommend" things in this scenario, as much as it's about helping the patient identify what they're willing to do/not do and what outcomes might result and what is the likelihood and the patient's risk tolerance. We can't tell patients what outcomes to value but we can recommend how to get there if that makes sense.

I refer to something I call the "vegetable risk" which is essentially the risk they come back as a "vegetable" (which I explain, someone who is technically alive but so brain damaged we don't think they have any awareness) vs the chance of significant organ/brain damage vs the chance of coming back mostly intact or "mostly as you are now."

Some people will take a very high risk of "being a vegetable" (and I literally use air quotes here) for a very low chance of coming back as they are, and what most people want is to come back to life as they are like we see on TV.

(The reality is that many people have a high tolerance for risk for coming back a vegetable for a low chance of coming back meaningfully intact. Which is fine if they understand that is the choice they are making).

Of course, none of this accounts for the in-between, which no one really wants, which is being intact enough to experience suffering but not intact enough for a quality of life one finds acceptable. For some people they would be fine with if they can still feed themselves and recognize loved ones, for others if they can't still read for example that won't cut it.

One issue is that there's basically no good way for me to predict exactly where on the spectrum things will go. I can only speak to who has maybe the "best" or "worst" chances of the two extremes, vegetable or coming back basically intact. So that is what I can try to advise about, but no one can fully predict.
In any case anything besides DNR carries the "vegetable" or "in there enough to suffer" risk that they must contend with. And that realistically in that case then things will be out of their hands and the decision making responsibility and caretaking will then fall to their family, and how comfortable do they feel with that.

And that if they come back "a vegetable" or "in-there enough to suffer" there might be very little family or physicians can be able to do at that point to let them go in peace.

Because some people have an expectation that you "see what you can bring back" and if it doesn't go well then you just "let them slip away" and sometimes it doesn't work that way, people are essentially vegetables or aware of suffering but get better enough that removing the ventilator and other machines and interventions, they keep on living for variable amounts of time, even years, after the fact. But they can't take any action or have any input to shorten their lives or refuse treatment at that point, they're kinda stuck.

So people need to understand the risks mainly, before deciding what they're willing to risk.

 

[FutureInternist]

I use “the chance of you coming back anywhere close to where you are now are very low” or something along those lines