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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