The last few passengers filter in and buckle themselves up before takeoff. The emergency exit row is occupied by an elderly couple, and I am seated behind them. The flight attendant asks whether they are comfortable in those seats, given that they’d have to respond in the case of an emergency.
“Not that I expect anything bad to happen,” the flight attendant adds with a smile.
I, too, am familiar with discussing worst-case-scenarios, in particular when I must determine my patients’ “code status” — the intervention patients would want if they were to stop breathing or if their heart were to stop beating. Would they want to be revived? Or would they prefer no action be taken?
If a patient does not want to be resuscitated, his or her code status would be “DNR” (Do Not Resuscitate). If a patient, on the other hand, wants life-saving measures, they would be considered a “full code.” This includes performing chest compressions, known as CPR, and using life support to help them breathe.
However, between a DNR and a full code lie numerous additional questions. For example, would a patient want to be transferred from the regular floor of a hospital to the intensive care unit if needed? If a patient were to get an infection, would they want to receive fluids? Antibiotics? Blood?
It’s necessary to know the code status of every patient admitted to the hospital. Even the code status of young, healthy patients should be documented. Just as the flight attendant reassured her passengers that the chances of an emergency occurring were very slim, I often communicate that I don’t expect anything bad to happen when discussing the code statuses of my healthy patients; rather, it’s part of standard protocol.
When patients are critically ill, however, the conversation becomes more serious. Knowing their code status is crucial. If a patient in the hospital becomes sick in the middle of the night, and no code status is documented, the default is to treat everyone as a full code, regardless of their wishes.
Despite the importance of the code status, many of the patients I look after in the hospital setting don’t know what it is. In addition, code status discussions need to happen at the right time and in the right place. I once had a code status discussion in a small emergency department room with only a thin curtain separating hospital beds. The patient’s health was deteriorating rapidly, so it was necessary to have the conversation right away. I wished such a personal discussion could have been confidential, but it wasn’t.
Most of the hospitals I have worked in have a section on code status on the admission form, which is a good reminder for health care staff that it needs to be addressed. However, the hospital is not the best venue for this discussion to take place. Asking someone to contemplate the details of their own mortality while they’re already feeling sick in the hospital is anxiety-provoking and an added task in an already stressful situation. Instead, we should move the code status conversation to the primary care setting. This way, physicians and nurse practitioners can provide education in a non-crisis situation allowing patients adequate time to think and evaluate what is right for them. It’s one less thing to think about, should they become acutely ill.
Time, as we know, is often crunched in primary care. However, this discussion doesn’t need to happen all at once. We can bring it up on one occasion, provide a handout, and have the patient think about it and go further into detail at a subsequent appointment. A colleague of mine told me that she includes a question about code status on her initial patient intake form, which is something I plan on adding to mine.
Back on the plane. I click my seatbelt, and we speed down the runway. I am back from the mental diversion of tubes, death and CPR. My stomach drops as we shift from ground to air, and I look at the elderly couple in front of me again. They are reading peacefully, probably no longer thinking about being emergency responders in a life-threatening plane crash. Humans are resilient. We can contemplate horrible scenarios and just bounce back to the present moment and live our lives.
Though the conversation about code status might be a difficult one, let it be one that we are not afraid to have.
Sarah Fraser is a general practitioner who blogs at Sinus Rhythm.
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