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Hospice and Full Code

Discussion in 'Hospice and Palliative Medicine' started by Spittz03, Feb 16, 2007.

  1. Spittz03

    Spittz03 Senior Member
    5+ Year Member

    Jan 28, 2006
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    Resident [Any Field]
    What does it mean when a patient is considered a Hospice patient, but expresses desire to stay Full Code? I was always under impression that a Hospice pt has to be DNR.. What are doctor's obligations for a patient that would like to remain Full code? Thanks for your input.
  2. jroosthmd

    Feb 15, 2007
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    Attending Physician
    Well, to my way of thinking it is inappropriate. However, as a Hospice Medical director, I can tell you of many cases where people are unwilling to accept the idea of having a DNR order. Over the years I have been involved in the care of many patients who seemed truly interested in the idea of being on hospice. They want the attention hospice provides, the access to comfort measures. They are unwilling to not be full code generally because they are unaccepting of their terminal condtion.

    I see it more often in younger patients who often have had the relatively sudden onset of a fulminant illness such as a Glioblastoma. They might be a younger professional person with a young family, young children, newly married. They wind up on hospice because they are told by their MD's there is nothing more that aggressive medical care can offer, but they are unwilling to make the leap to the point of accepting that they are going to die.

    In some cases it is particularly sad, where the patient still has their full faculties and therefore still has the decision making capacity. Often patients come on our service and do want to be full code, but as they see themselves deteriorate they often realize the inevitable and sign. It is painful, but that is how in sometimes goes.

    Then I have actually seen some who never were willing to sign, and yet perhaps their primary care giver really understood their terminal status and when they passed, simply ignored that they had said they wanted CPR. It may not be exactly legal, but it happens.

    And then there have been a few very unfortunate souls who not only wanted to be full code, but their primary care giver also wanted them to be full code and when they died CPR was 'sucessfully' administered only to have them linger in an ICU for several days before the true meaning of the futility of the situation resulted in ventilator withdrawl.

    I've only been doing this, with great frequency for 5 years and I am sure someone with more experience might have answered your question more eloquently. But the bottom line as it were is that you do not have to have a signed DNR to be on hospice. There MAY be some hospice organizations that will not bring on a patient who does not have a DNR, but for most it is not a prerequisite.

    Honestly, my first thought when this was discussed at a conference I attended was that to be on hospice MEANT you HAD to be DNR, but it just aint so. Probably an area that will be debated forever.

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