Patient advance directives are critical in the ICU

When someone dies at home we call it ‘going to a better place.’ When someone dies in the hospital we call it a ‘code.’

Recently, working in the cardiac ICU, I have been thinking a lot about code status. Code status is the medical term that describes what a patient’s wishes are should his or her heart stop or lungs fail. While code status is not a topic that typically comes to mind when we think of preventive health, to me many of challenges related to code status are preventable.

The case of Mr. GR — a 79-year old man with end-stage pulmonary hypertension I took care of in the cardiac ICU recently – illustrates the point.

Mr. GR had been in the ICU for several days teetering on the edge of fulminant heart failure when one morning after rounds I was called to the bedside because his breathing had become labored. From the doorway it was clear that, if we were to be aggressive, he needed to be urgently intubated. The question was: how aggressive exactly did we want to be? With end-stage disease, his quality of life was poor as it was and after this hospitalization — if he survived — it would only be worse. As we got a stat set of labs and xray to rule out any immediately reversible cause of his rapid decline, I paged the heart specialists to find out if they had anything else to offer. The response was brief – there was nothing more they could do. Because Mr. GR was now obtunded and no longer conversational, it was time to talk to the family about code status.

For such an important decision code status is too much alphabet soup. Patients who do not wish to undergo chest compressions or electrical shocks if their heart fails are said to be DNR (Do Not Resuscitate). Patients who do not want to be intubated for respiratory failure are DNI (Do Not Intubate). Patients who want “everything done” are Full Code. Thus patients can be broadly categorized as Full Code, DNR, DNI, or DNR/DNI.

Every patient who is admitted to the hospital is supposed to be asked about his or her code status. In practice doctors are variably compliant about this. Most of us would ask an 80-year old with terminal cancer coming in short of breath what his code status is. However, it seems awkward and unnecessary to do the same for a 30-year old being admitted for an infection of the leg.

On admission, Mr. GR stated he was Full Code. However, it is unclear what the conversation entailed. Even when doctors ask about code status, we don’t do a very good job of it. Studies show the conversations generally last 2 to 3 minutes with the physician doing most of the talking. Each of us describes code status differently. And hardly anyone tells patients about their expected prognosis should they survive a resuscitation, and definitely not in terms patients can relate to. Either way, code status needs to be re-addressed if a patient clinically deteriorates. And this was certainly the case for Mr. GR, except that now, given his condition, it would need to be done with his family.

After I explained the prognosis, the family, somewhat hesitantly, decided that he would not want to be intubated. “We don’t want him to suffer.” I told them we would do our best to make him comfortable and that in the mean time they may want to have additional family members come and say their goodbyes. An hour later I was paged. The family had changed their minds. One family member swore that Mr. GR woke up and in a moment of clarity said he wanted to be intubated. Seconds later I was overhead paging anesthesiology and minutes later he was intubated and on a mechanical ventilator.

With 21st century medicine we have an uncanny ability to keep people alive. But that doesn’t mean we always should. There is quality of life, not just quantity, to be considered. This power has brought with it the need for careful judgment. A hundred years ago we could do “everything” for every patient and not have to worry about artificially prolonging suffering. But that is no longer the case today.

An hour later Mr. GR’s oxygen levels and blood pressure were dropping. Sensing the inevitable, I rushed to get the family to beside to re-address code status. I told him that I suspected his heart would give out at any moment and that I strongly recommended we not resuscitate him if that were to happen. The likelihood of him walking out of the hospital was almost zero.

But just as the family were deciding what to do he flat lined. Three nurses rushed in — “Dr. Nundy, should we call a code?” I looked at the family, their faces in horror. “DOCTOR, ARE WE CALLING A CODE?” The family was balking and if we were to resuscitate him every second counted. I looked at the family’s faces one more time. No decision. “CALL A CODE!” I jumped on the chest and started performing compressions as the alarms rang calling for the “Dr. Cart” team. Within minutes, a dozen of so nurses, surgeons, anesthesiologists, and internists were pouring into the room and the code was in full swing.

A code is a hospital emergency, generally called when a patient’s heart stops. Codes in real life are much like the codes on the television show ER. They are adrenaline-rushed, chaotic and emotional. The only difference is that in real life codes don’t turn out well. On television we see a patient going from asystole to hugging his family in five minutes flat. In reality most patients don’t survive in-hospital codes; those that do usually do not survive the hospitalization.

Incredibly Mr. GR survived the code. With his blood pressure now supported by three different I.V. medications, the blood flow to his heart had resumed and his oxygen levels had normalized. While the numbers on the monitor were better, Mr. GR was not. He was still unresponsive and showing few signs of actual life. Still my intern and I stayed with him all night, tweaking this, increasing that. But by morning there was little improvement. After another lengthy discussion, this time with the senior cardiologist, the family decided to withdraw care.

Death cannot always be prevented but it can be planned for. There are two lessons here. The first is the importance of an advanced directive. Advanced directives, or living wills, are formal instructions people give specifying what actions should be taken for their health should their capacity to make decisions for themselves become impaired.

Mr. GR had not formally indicated what his wishes were should his breathing become worse. With end-stage pulmonary hypertension we might have expected a scenario like this to eventually come one day. But without specific guidance, members of the medical team, and his family, were at a loss for what to do and were left conjecturing about what Mr. GR would want.

The second lesson is the value of having a POA. A power of attorney, or POA, is person given legal authority to act and make decisions on someone’s behalf. Not all clinical scenarios can be anticipated in advance. At the same time, with multiple loved ones, in times of stress, there is often great uncertainty about who ultimately should be the decision maker. The night we decided to intubate Mr. GR there was at least 10 family members present. Because no one wants to be the one to decide to “give up,” often the tendency is to continue onward.

Mr. GR passed away later that day. The overall feeling I got from the family was one of relief. But there was also a sense of satisfaction. In their minds they had done everything. If they had not decided to put Mr. GR on a breathing machine they might have wondered “what if.” At the same time, I wondered for Mr. GR. I wondered how much suffering we put him through and how much he actually sensed – me pushing on his chest 100 times per minute, us shocking him three times, fluid pouring into his lungs – and for what?

I don’t blame the family for what they did. After all they will be the ones to live with this memory for years to come. But stepping back a moment it needn’t have been this way. With an advanced directive and power of attorney, the family may still have left content that they did everything Mr. GR wanted them to do, and at the same time, Mr. GR may have died on his own terms with more dignity. Death isn’t always preventable but codes can be.

Shantanu Nundy is an internal medicine physician who blogs at BeyondApples.org.

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