“If your heart stops working, or if you stop breathing, would you like resuscitative efforts like CPR or a breathing tube down your mouth?”
This is how I ask about code status, that tricky, vaguely legal-sounding term that determines whether a code–an all-out, no stops combination of CPR and ventilation–is called on a patient if they need it. I’ve struggled to find the perfect prepared statement to talk with people about a really profound issue: when it comes down to it, if you’re dead, do you want us to do unnatural things to try to bring you back, or do you want to be let go?
There are several options for code status: full code means all systems go, do whatever you can do to try to bring me back. DNR/DNI stands for “do not resuscitate/do not intubate” which means no CPR or mechanical ventilation. Then, there is CMO, or “comfort measures only,” which is pretty much what it sounds like–this status alerts me that the patient should only receive care that will make them more comfortable, like extra pillows for back support, pain medications, sleep medications, or even a cool fan to make their breathing easier. There’s a lot more details, but that’s the gist of it.
A couple of common scenarios: sometimes people request a “time limited trial,” meaning that they want to be full code, but are willing to be let go after a few days if their prognosis seems poor. Sometimes a person will request to be DNR but not DNI or the other way around; this designation is problematic because it would mean doing some interventions but not enough to truly save a life. It doesn’t make medical sense, and when I get patients with this code status, I try to have a conversation to figure out exactly what they mean. (Example: I recently spoke with a woman’s daughter who clarified that her mother was DNR, but hadn’t made her DNI because she still wanted her to receive non-invasive ventilation like BiPAP if necessary.)
Code status is essential to know for emergencies. But more than that, code status guides my decision-making about the patient every day. If you’re the kind of person who doesn’t want mechanical ventilation, are you really going to want more invasive treatments that could send you to the intensive care unit? If you are DNR/DNI, and 85 years old, are you going to be the right candidate for heart valve surgery, knowing that there is a greater than 5% risk you could end up with stroke or worse? It helps me predict what kind of course a patient may take.
Code status allows me to see the bigger picture about my patient: if you’re young and healthy, it makes sense to be full code, but if you’re not, is there some reason why? If you’re 90 years old and demented, but still full code, is that really what you want or would that only prolong your suffering? Weird code status that didn’t correspond with the patient’s level of health has led to me having discussions with patients and their families about why, and I have learned so much about different cultural attitudes, how personality plays a role, and the mediocre job we do at explaining the different options for end-of-life care.
What really frustrates me is that as an inpatient resident physician, I should not be the one asking about code status. Who should? The primary care physician. I make a point to ask my personal panel of clinic patients about advanced care planning after we’ve met 3-4 times. By this point, they are comfortable with me, and I know them better, too. I tell them that advanced care planning is a flexible decision, and they can change it at any time, but it’s better to start thinking about it earlier. I encourage them to talk with their family and loved ones. I give them the MOLST form, the Massachusetts version of an advanced care planning form, which asks specific questions about whether they would want ventilation, CPR, artificial nutrition, etc.
If I have learned one thing about code status, though, it is how much FEAR drives decision-making at the end of life. Even if the patient has an advanced care plan, fear can cause them or their families to be thrown into emotional turmoil about deciding what kind of resuscitative efforts, if any, would be best. Priorities get lost, and I think the most important thing to remember is that decisions should be made based on what the patient him or her-SELF would want, not anyone else. It is hard, it may be draining and require lots of thinking and talking, but it is one of the most important decisions that a doctor can help someone make.