DNR/DNI

[deleted1053216]

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1. While in hospitals, how do you have the code discussion with your pts? Are there specific questions you ask them to assess this? DNR/DNI vs. Full code. If I ask them simply given xyz situation, do you want to be intubated is that enough and legally binding or do I have them fill a form.

 

[deleted480308]

1. While in hospitals, how do you have the code discussion with your pts? Are there specific questions you ask them to assess this? DNR/DNI vs. Full code. If I ask them simply given xyz situation, do you want to be intubated is that enough and legally binding or do I have them fill a form.

Discussing Code Status

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...

forums.studentdoctor.net

 

[AMEHigh]

No you don't have to fill out a form. A patient can change their mind about code status day to day, you just need to update it in the medical record and with the medical team.

My general hospital spiel was something along the lines of "since you're going to be in the hospital with us we want to give you the care that you want. We ask everyone when they come in to the hospital if they've discussed code status with family or friends regardless of age or why they're here. Code status involves making decisions around wanting life saving care in the form of cpr and a breath tube. Have you made any decisions surrounding this?"

Something along those lines. It can definitively take up time during the admission process, but well worth it to have those discussions every time.
If it's a more complicated case, definitely get the palliative care team involved to help you navigate these conversations and decisions, they're so valuable!

 

[deleted87716]

“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) “

Pretty much the way I used to do it.

 

[hallowmann]

1. While in hospitals, how do you have the code discussion with your pts? Are there specific questions you ask them to assess this? DNR/DNI vs. Full code. If I ask them simply given xyz situation, do you want to be intubated is that enough and legally binding or do I have them fill a form.

I ask 4 questions, after a spiel about asking all patients when they come into the hospital, although we don't anticipate this happening: If your heart were to stop would you want chest compressions? If you were to stop breathing, would you want a tube placed down your throat for a machine to breath for you? If you required a higher level of care such as medications or breathing support that we cannot provide on the floor, would you like to be transfered to the ICU for more intensive care? If you were unable to make decisions for yourself regarding your care, who would you like to make those decisions for you?

If they have questions, I answer it, but I try to avoid certain language like "save your life", "do all we can", "bring you back", and even "let you die naturally", because I feel like all of those are a bit loaded. I make it clear that they can change their mind at any time in the future, but that this is just to make sure we do what they would want for themselves.

 

[Candidate2017]

Very old, super ill: "BTW, if grandma's heart were to stop, would she prefer us to do CPR, pound on her chest, possibly break some ribs and bones with no guarantee it would work? If she were to stop breathing, would she prefer us to stick a tube down her throat and have a machine breathe for her?"

Relatively healthy: "A couple of questions we ask everyone. If god forbid your heart stopped, is it ok if we do CPR? If you stopped breathing, is it ok if we put in a breathing tube?"

In reality, no one's is going to pull up the chart during a code and most everyone gets pounded on.