Code Status Discussions; Difficult but Necessary

I thought it was just where I practiced, but it turns out that, in the medical field, we’re really bad about having code discussions, which is a significant issue. When some of my patients revealed that no one had ever asked them about their code status before, I decided to conduct some research on this topic. It turns out that, at most, 41% of patients recall discussions about their code status, however, the 10.3% as documented by another study seems much more accurate.^1,2

I will admit I’m far from perfect, but my experience caring for intubated patients during the COVID-19 pandemic compels me to broach the subject as frequently as possible. Though I am taking care of less-seriously ill patients than before, those heartbreaking experiences shape how I view these non-beneficial interventions. However, I can’t describe the meaningless gesture that many codes become to my patients. Despite our inaccuracies in predicting mortality, or whether a person will survive a code, patients deserve the use of this knowledge, and squeamishness about having the conversation should not prevent this.^3,4 As I put forth more effort towards having these conversations I find I am better able to convey the ethical challenge a code presents to us as physicians.

This is a unique topic, as it involves discussing difficult subjects. It seems that we’re more prepared to talk about just about anything else than the practice of performing non-beneficial chest compressions on someone with no chance of surviving. Physicians have a different approach to end-of-life care compared to the general public. We tend to avoid aggressive life-saving treatment and prefer to die at home.^5,6 As health care professionals, it’s our responsibility to share our knowledge and experiences to help our patients. If we fail to share our honest opinions about end-of-life issues, it becomes a problem.

As a hospitalist, discussing death with patients can be uncomfortable, especially when trying to establish a therapeutic relationship with them. However, it’s important to ensure that patients understand the scope of care they may receive, regardless of how ill they may be. Even though some may avoid or briefly touch on the topic due to limited time, it is still part of our duty to have an honest conversation with the patient. This may affect how patients perceive their hospitalization in the short term, but studies show that a month later, it won’t affect their review of the hospitalization.⁷ Ultimately, providing clarity on what interventions the patient is willing to undergo is essential.

Occasionally I run into patients who have had an honest discussion with their family about their end-of-life care, and they’ve documented their wishes in a health care power of attorney document. Most of these patients live at an assisted living or skilled nursing facility, and while this is a powerful predictor for having prior discussions regarding end-of-life care, it doesn’t guarantee this has occurred.⁸ Often the patient states they have a health care power of attorney document and are a bit frustrated that I want to discuss this again. Assuming the patient is still able to make decisions for themselves, I explain that it’s great that they have this document, but that it doesn’t tell me what to do in an acute emergency, and since they’re here right now and able to discuss these topics, we should do so. 

The conversation about code status should of course involve a discussion regarding the patient’s wishes surrounding intubation, cardioversion, pressor support or inotropes, and the associated central line. Asking about these details first allows me to understand the patient’s goals and prepare them for further questions about intubation and cardioversion or chest compressions. I stress that choosing a partial-code status essentially guarantees failure.⁹ If the patient still wants intubation but no chest compressions, I take this as a lack of knowledge and wade back into the conversation and reiterate the importance of understanding their decisions. If the patient expresses a wish to be full-code, I ask them to consider the appropriate duration of a time-limited trial of ICU care should they end up intubated, sedated, and stabilized. Regardless of what they choose, I stress the importance of sharing this information with their family, particularly the person responsible for their health care power of attorney.

As stated above, attempts at resuscitation where chest compression or cardioversion are not used have no chance of meaningful survival, whereas codes where the patient does not need intubation are predictive of an improved outcome.⁹  If a person codes outside the hospital they have roughly a 7% chance of surviving to discharge from the hospital.¹⁰ The rate of survival to discharge for patients who have a code in the hospital setting appears to be around 15%, and has been surprisingly stable over the past 60 years; though the “Get With the Guidelines” data is much more optimistic, reporting a 25% survival to discharge rate.^11,12,13 I feel it’s important to stress that this is an intervention with poor results and the process is traumatic at best for the person receiving cardiopulmonary resuscitation. Multiple risk-stratification scores can be used to guide these conversations, the GOFAR score being the preferred one currently.⁴ While these are helpful, they are not perfect, and no score can predict with certainty that someone will not survive a code situation.

How we approach this conversation about end-of-life care is the subject of a great deal of research. The clear recommendation is to make this a shared decision between you and the patient, but the method of doing so remains up for debate.¹⁴ After going down this rabbit hole, I found much of it was splitting hairs about how much our biases influence the discussion of end-of-life care, and whether this is appropriate. I worry this may be a case of the perfect getting in the way of the good and that these debates are more likely to disincentivize discussions rather than make them more effective. There will never be a perfect method to introduce the idea of possibly dying to a patient who is already upset and scared because they just found out they are sick enough to require admission to the hospital. In every discussion, I try to emphasize that I will do everything possible to prevent the illness from progressing to this point, regardless of the decision made. Although a negative outcome is likely, I will give every ounce of myself to honor their wishes.

The script I’ve used since residency is terrible and frames coding as if it occurs in a vacuum, without any connection to the patient’s illness. Lately, I’ve been trying to change that by showing how coding fits into the bigger picture of a disease process. For example, I explain how a patient’s heart stopping or their lungs failing to provide adequate oxygenation represents a significant threshold in the continuum of a disease process.

An example conversation might be: “I don’t expect that your heart failure exacerbation will worsen now that we’re starting therapy, but heart failure is a serious disease. As it progresses, the likelihood of serious complications increases. This may progress to the point that your heart is not able to function without intravenous chemicals to support it. Is that something you would be willing to tolerate, with the goal of weaning off these medications eventually? As heart failure progresses, the likelihood of an arrhythmia occurring increases as well, If your heart enters into one of these rhythms it no longer pumps blood effectively, and your brain starts dying without adequate oxygen. We can try to return it to a normal rhythm by performing chest compressions and shocking the electrical system, but the likelihood of success is very low. Is this something you would want to be done if your heart becomes this ill? As your heart failure progresses, it may lead to fluid collecting around your lungs, making it harder to breathe. If this happens we can use a mask to help while attempting to remove this fluid, but this is not always successful. Would you be willing to have a tube inserted into your throat to allow us to assist your lungs, with the goal of removing the tube later, understanding that this may not be possible?”

Discussing the nature, progression, and severity of a patient’s disease can help them better understand their situation. These conversations often force patients to consider the real-life implications of their decisions, which can be scary. However, this honesty can lead to meaningful discussion and decision-making, even if a decision isn’t reached right away. Simply having the conversation can help patients consider their options and make future discussions more productive.

Some special programs and facilities provide professional patients for medical practitioners to practice and improve their communication skills. Although these programs are effective, the easiest way to get better at communicating with patients is to prepare beforehand and then engage in conversation. I sometimes find myself in awkward situations during patient interactions, despite my best efforts. However, I have noticed an improvement since I started focusing on this aspect of my care. With enough practice, these conversations will become easier and eventually become a routine part of our daily work.

I admit, I still don’t know how to introduce my pessimistic view about the process without feeling like I overwhelmed or browbeat the patient into agreeing with me. This raises internal concerns about paternalism, so I usually stick to hiding behind the statistics I listed above. I recognize this is going to be an ongoing process of self-improvement and I think the most important thing is to start having these conversations regardless of our concerns about not being good at it. There will be awkwardness, regardless of how good you are at the conversation, and besides, as Adventure Time’s Jake the Dog says, “Dude, sucking at something is the first step to being sorta good at something.” 

Dr. Menet

Dr. Menet is the chief hospitalist officer at Beam Healthcare in Madison, Wis.

References

1. Becker C, Künzli N, et al. Code status discussions in medical inpatients: results of a survey of patients and physicians. Swiss Med Wkly. 2020;150:w20194. doi: 10.4414/smw.2020.20194.
2. Young JS, Bourgeois JA, et al. Sleep in hospitalized medical patients, part 1: factors affecting sleep. J Hosp Med. 2008;3(6):473-82.
3. Stone, PC, Chu C, et al. The accuracy of clinician predictions of survival in the Prognosis in Palliative care Study II (PiPS2): A prospective observational study. PLOS ONE. 2022;17(4):e0267050. https://doi.org/10.1371/journal.pone.0267050
4. Wyckoff MH, Greif R, et al. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces. Circulation. 2022;146(25):e483-e557. https://doi.org/10.1161/CIR.0000000000001095.
5. Gramelspacher GP, Zhou XH, et al. Preferences of physicians and their patients for end-of-life care. J Gen Intern Med. 1997;12(6):346-51.
6. Weissman JS, et al. End-of-life care intensity for physicians, lawyers, and the general population. JAMA. 2016;315(3):303-5.
7. Anderson WG, Pantilat SZ, et al. Code status discussions at hospital admission are not associated with patient and surrogate satisfaction with hospital care: results from the multicenter hospitalist study. Am J Hosp Palliat Care. 2011;28(2):102-8.
8. Russell E, Hall AK, et al. Code status documentation availability and accuracy among emergency patients with end-stage disease. West J Emerg Med. 2021;22(3):628-35.
9. Dumot JA, Burval DJ, et al. Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of “limited” resuscitations. Arch Intern Med. 2001;161(14):1751-8.
10. Berdowski J, Berg RA, et al. Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies. Resuscitation. 2010;81(11):1479-87.
11. Aiqun Zhu, Jingping Zhang. Meta-analysis of outcomes of the 2005 and 2010 cardiopulmonary resuscitation guidelines for adults with in-hospital cardiac arrest. Am J Em Med. 2016;34(6):1133-9.
12. Schneider AP, Nelson DJ, et al. In-hospital cardiopulmonary resuscitation: a 30-year review. J Am Board Fam Pract. 1993;6(2):91-101.
13. Benjamin EJ, Virani SS, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67-e492. doi: 10.1161/CIR.0000000000000558.
14. Kon AA, Davidson JE, et al. Shared decision making in icus: an American College of Critical Care Medicine and American Thoracic Society Policy Statement. Crit Care Med. 2016;44(1):188-201.