Why full code should not be the default status for patients

Full code is the universal default status for patients who haven’t chosen otherwise, but I suspect most physicians believe this policy is wrong. We know in our hearts we’re doing harm when we perform CPR on poor souls at the natural end of their lives, whose bodies can do nothing more than suffer.

Appropriately timed end-of-life discussions are the supposed answer, but for doctors they are emotionally draining, interpersonally complex, and when done properly, overly time-consuming. For a busy and stressed physician caring for an acutely ill patient, it’s easiest to either avoid the discussion entirely, or stick to concrete verbal formulations, putting the patient or the family on the spot with ridiculous questions like “Do you want us to do everything?” … “If your heart stops, should we restart it?” … “If he stops breathing, should we put him on a breathing machine?”

One major source of the complexity is the irreducible uncertainty in the prognosticating of survival after in-hospital cardiac arrest. As an example, a majority of patients suffering ventricular tachycardia/fibrillation on the medical ward may survive to discharge with good neurologic outcomes, while <2% of those with PEA arrests while on pressors in the ICU do. Hospitals’ response to this ambiguity has been to play it safe by maintaining the universal “full code” default, and the courts have avoided making any guiding rulings in the area, preferring to leave it to health professionals. The result is an excessive burden on physicians that essentially demands we climb this difficult mountain with every new patient, every family, every time. But the real burden falls on thousands of patients each year, who are “successfully resuscitated” but with brain injuries they never would have wanted to survive.

So thank goodness that Craig Blinderman, Eric Krakauer, and Mildred Solomon of Harvard are talking sense about CPR in JAMA, arguing we should stop offering CPR as the default option for hospitalized patients — and should simply inform families we are withholding it in dying patients, without asking for their permission. (It astounds me that it’s taken this long for an editorial like this to make it to a major journal, but better late than never.)

They propose 3 scenarios:

  1. For the average chronically or acute-on-chronically ill patient (like someone with a heart failure exacerbation), doctors should discuss CPR as a possible (“plausible”) option — spending ample time on the low chance of survival to hospital discharge and the risk for brain injury.
  2. For patients with incurable advanced cancer, end stage liver disease, or advanced dementia, doctors should recommend against CPR.
  3. For patients who are imminently dying, we should withhold CPR as a futile, harmful therapy, and simply inform the families of this. Authors advise, “Not offering CPR for imminently dying patients should be explicitly permitted by hospital policy.”

There’s a problem with option 3, though: Today, almost exclusively, it’s not hospital policy. Full code is. Hospitals sell out and undercut us physicians by not trusting us enough to let us make these judgment calls and promise to support us afterward — presumably because they fear lawsuits or being labeled as a “death panel hospital” — and the problem is perpetuated.

Kudos to these authors for calling for what’s simply right. Don’t expect a change in hospital or national policy, though. The inescapable reality that makes this issue so politically combustible is that though this approach is reasonable and caring, implementing it would nonetheless result in some people dying prematurely or unnecessarily. A handful of people with terminal diseases would have “V-fib” arrests that were quickly reversible with an electric shock, or respiratory arrests from curable pneumonias. CPR or intubation with a ventilator would buy them a few more months or even years of life, but under this policy those relatively uncommon patients would be allowed to die.

Of course, that would spare many times more people from undesired prolonged, uncomfortable, vegetative ends to their lives. But try putting all that into a sound bite and selling it on the Senate floor or on cable news.

Matthew Hoffman is a fellow in pulmonary and critical care who blogs at PulmCCM.org.

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  • http://twitter.com/redbirds12 John Key

    I was expecting to disagree with this post, but I didn’t–in fact, this was the manner in which codes were handled when I was a student in Galveston circa early 1970′s.  Of course this was pre-ACLS, pretty much even pre-code protocol of any kind. There was a blackboard in the service conference room, that listed which patient was a “no code”, a “slow code” or a “full code”, based upon the patient’s condition and prognosis.  I don’t believe the “code status” was ever discussed with the patient or family–it was a purely medical decision.

    Right or wrong–you be the judge.  I think it was right.  Our profession has abdicated a lot of our previous responsibilities, and it is high time we reclaim the ground we have given up. 

    • drseno

       Are you suggesting that physicians not discuss code status with patient and family?

  • creggztr

    i can really apreciate this story, i’m a respiratory therapist called for  terminal extubations days or weeks after a patient is a vegetable or in pain. the ones that are literaly decomposing and the family is given hope and often several of these patients at a time is extremely depressing. sometimes these patients are sent to med floor on a ventilator and not observed for very long periods of time. agonizing every minute that goes by.this is not quality of life ,nor is it alowing dignity to the patient. even a transfer between acute hospital to a LTAC code status is ignored untill it can be redone on thier forms. i would not want to be treated with torture in a hopeless situation.

  • John Henry

    Full code is the default status due to medico-legal concerns over being accused after-the-fact of not having done all that was possible to do in a cardiac arrest scenario. This requires a legislative response that allows the medical team to determine an appropriate code status that–and this part is important–may not be challenged later for any reason. Short of that, there will be no meaningful change.

  • Doug Rothermel

    I enjoyed reading this post by Dr. Hoffman. End of life care is a discussion that needs to be elevated, and who better to talk about it than the doctors that provide the care.

  • http://www.facebook.com/profile.php?id=562669216 Margaret Kraft

    As a nurse for 25 years, I agree fully with the proposed scenario.  I agree with the fact that it would, indeed, be a hard sell.  Our culture has a view of death that makes doing anything short of “anything and everything possible” seem like giving up.  The result is that far too many people end up dying in the hospital hooked up to machines even though most would say that they do not want to die in that manner.  In addition the  fear of lawsuits causes many problems.  I spoke with a friend yesterday about her father’s death.  He had sever early Alzheimer’s and had given her POA for Healthcare.  However, when she chose hospice care and her brother dissented, the physicians were unwilling to proceed with that plan of care until all the siblings were in agreement.  She was very frustrated that her father’s pre-planning wasn’t sufficient when a somewhat estranged son chimed in.  I wish there were easier answers to this very complex problem.

  • http://empoweredpractice.com/ Trista

    As a respiratory therapist in a rural community, my patient interaction is often with patients that you are talking about in this article: end of life, chronic, etc. Like Margaret and John, I have seen similar situations of pre-planning decisions being placed on hold for various reasons. I feel most providers struggle with the decisions some families make when it comes to code status. I have often asked why? I think this is a great proposal for policy in hospitals as long as it doesn’t remove the code conversation all together, which I would guess it would not. Patients would still have to be informed of the policy. It would certainly make the conversation more educational for those involved, over those ridiculous questions you mentioned. Rather than saying “yes, do everything” the policy could open the response from family up to “why would that be so” allowing you to answer custom to the patient’s status, prognosis and quality of living. Most times, people don’t think of that in the moment. I would love to see this type of policy in our hospital.

  • http://medicalethicsandme.org/ Carol L. Powers

    Please see the Community Ethics Committee Report called “Withholding Non-therapeutic CPR” which preceded and in some ways underlay the JAMA article (Craig, Millie and Erik are familiar with our work).  It can be found at our website/blog “medicalethicsandme.org”.   (We are a truly diverse group of volunteers from the community surrounding the Harvard teaching hospitals; we write Reports on policies and issues that are of concern to the community; and I am the Chair of the Committee.)

  • http://twitter.com/DRSALWITZ James C Salwitz

    Remarkable idea, but I have too contrary thoughts.  First, in our present environment, mandating code decisions (beyond guidelines) based on diagnosis would result in horrendous emergency room, intensive care unit and court room conflicts with families that had not yet coped with the reality of the disease. You still need that critical family meeting and education. Second, more important, as a physician I have found end-of-life conversations to be invigorating, life affirming, properly complex to the human condition and, if done well, time saving. It is was we do.
    jcs

  • http://www.tumblr.com/tabbiecat66 Tracey A

    whats worse is when a patient actually has a living will, on the chart, but the family or doctors or whomever, decides that really isnt what the person meant or needs.  Going directly against the patients intended wishes. I see that way too often as an ICU nurse for the past 16 yrs. 

  • http://twitter.com/genespiritus Gene Spiritus

    As a physician who practiced pulmonary critical care for more than 20 years and spent 13 years as a CMO in an Academic medical center I was appalled by your comment “Appropriately timed end-of-life discussions are the supposed answer, but for doctors they are emotionally draining, interpersonally complex, and when done properly, overly time-consuming. For a busy and stressed physician caring for an acutely ill patient, it’s easiest to either avoid the discussion entirely, or stick to concrete verbal formulations, putting the patient or the family on the spot with ridiculous questions…” It is precisely because physicians have been unwilling to spend the time with patients who have chronic diseases that have a poor prognosis  long before they arrive in an ICU that this situation has developed .  Critical  physicians are perhaps the most capable of having a compassionate conversation with patients and families when code status has been previously neglected.  As draining and time consuming as they might be you need to come to the  it is an important part of your job.  With all the hoopla that was raised about “death panels” when the Healthcare law had a provision for physicians to be paid for end of life discussions it is folly to think politicians or hospital administrators will wade into a politically charged fight.  For better or worse physicians need to be more adept at having discussions regarding palliative care and advanced directives.  There are too many patients who never are given the appropriate information to make informed discussions.  Many times I have heard colleagues say I did not to take their hope away when the clearly need less intruisive care 

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