5 essential concepts to know about code status

Full Code.  Do not resuscitate.  Do not intubate.

Ask anyone without a personal or family history of a hospitalization on the implication of these terms and you’d likely get a blank stare in response.

Unfortunately, this incomprehension often rings true with those who need to know it most: the hospitalized patients themselves.

Many clinical reports (see here and here) have demonstrated that most physicians are not only inadequate in discussing code status with their patients but also have a tendency to avoid these discussions due to time constraints and fear of patient dissatisfaction.  This lack of effective communication can result in medical mismanagement, unnecessary grief, and avoidable legal consequences.

Before I offer the reader some quick tips relating to code status, let us first review the basic definitions behind this area of medicine and the implications of being labeled as full code vs. do not resuscitate/do no intubate (DNR/DNI).

Decoding the code

The term “code status” essentially describes what type of intervention (if any) a healthcare team will conduct should their patient’s heart stop beating or lungs stop moving air in the event of a medical emergency.

When a patient with a full code status has an acute episode where his or her heartbeat is on the verge of stopping or has completely stopped, the healthcare team will often provide emergent measures in attempt to resuscitate the patient.  This may involve chest compressions, electric shocks, and emergency medications that act to temporarily keep blood moving to essential organs such as the brain.

If this same patient begins to have problems breathing to the point where he or she might not be able to provide enough air movement to survive, the team will often place a tube into the lungs in order to mechanically provide enough air movement to keep them functional for a period of time.  This intervention is commonly referred to as “intubation.”

It is important to note that patients who come into the hospital are automatically considered full code until they either provide verbal or written instructions to not have these interventions performed on them in the event of an emergency.  In this scenario, the patients’ code status will switch from full code to DNR/DNI.

Below are a few important and often unrecognized considerations that patients and their families should be aware of when discussing code status with their healthcare team.

5 essential concepts to know about code status

1. DNR/DNI does not imply that a medical team will do nothing in the event of a patient emergency or that the patient will get substandard care during the course of their hospitalization.  Alternatively, full code does not imply that the medical team will continue interventions on a patient that they deem futile.

2. As long as a patient has capacity to do so, he or she is able to change their code status at any point during his or her hospitalization.

3. Although it is commonly not recommended, a patient may opt to have only certain interventions done in the event of a medical emergency (e.g. DNR but okay to intubate)

4. A code status discussion is considered a discussion for a reason.  Because the topic of code status can be confusing to many, it is important for the patient and his or her family to ask questions and express concerns rather than passively listen and reflexively respond.

5. Patients and their families should recognize that a code status discussion is never an easy one for a physician to engage in.  Although doctors may appear insensitive or awkward during this conversation, their intentions are to advocate for their patients and to practice medicine that is in line with their wishes.

Take home point

A code discussion is an integral part to any hospitalization. If conducted well, it will make a patient’s hospital stay a much more fluid experience. If not, the lack of communication may lead to undesired patient outcomes and unnecessary distress to all involved.

Empowering the general population with a basic understanding of code status can better avoid these potential medical errors in the case of unanticipated hospitalizations.

So spread the word.

Brian J. Secemsky is an internal medicine resident who blogs at The Huffington Post.  He can be reached on Twitter @BrianSecemskyMD.

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  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    As someone who cares for an aging geriatric population, these questions are reviewed and discussed with the patients when they are still competent and able to make decisions about themselves. This all changes when they lose that capacity and their health care surrogates take over. Often their understanding of situations clearly discussed and documented is significantly different from what their loved ones had requested. As their designated power of attorney or health care surrogate they have the ultimate say on these decisions

    • EmilyAnon

      So let’s say that the patient wants all heroic efforts to keep themselves alive and signed documents are in their file stating so. Then along comes a family member (surrogate) who challenges that and wants to withhold those heroic efforts (with the secret motive to get their inheritance as soon as possible), the doctor is then obliged to obey the family member’s wishes over the patient’s? Doesn’t seem right.

      • MELVIN RAY

        Good observation. In Texas this would (in theory) not happen because the patient’s right to make their own decisions, even at a time in the future when they can not speak, is protected by law, not to mention ethics and morality. The surrogate is obligated to answer the right question, “What are the patient’s known desires?”, not the wrong question, “What do you [surrogate] want to do?” The situation above calls for an ethics consult, unless the doctor has a spine – and she should know all along what the patient did, or did not, want. As a Board Certified Chaplain, Ethics Consultant, and Advance Care Planning Facilitator, I can testify that “the system” will take the path of least resistance (right or wrong) unless someone stands in gap.

  • http://www.facebook.com/phil.wiechart Phil Wiechart

    The doctor has a friend in the board certified chaplain. Chaplains can be helpful to patients and families in talking through code status decisions. Often these discussions require time and cultural sensitivity, which chaplains have to give. And chaplains get the spiritual implications of a decision that points to end of life.

  • http://www.facebook.com/shirie.leng Shirie Leng

    Fantastic discussion. Should be required reading for patients.