Episode 9: Code Status

What are your wishes in a critical situation? What measures would you or your loved ones want? Let's talk about your options.

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Transcript

Hello and welcome to Inside the ER. My name is Dr. Padraic Gerety and I’m a practicing, board certified emergency physician.

Yes, yes, I’m still alive and we’re back from our unofficial hiatus and today you’re joining us for our ninth episode, entitled, “Code Status.” No, this isn’t the name of some trendy movie about hacking or something. This is a potentially depressing topic, so be forewarned! 

Before we get into it, make sure to check out our previous episodes and then write me a scathing critique at insidetheer@gmail.com 

Oh, and we have a website now! It’s not much, just another place to listen, but hey, give it a look: insidetheer.buzzsprout.com that’s insidetheer.buzzsprout.com.

All right, enough shameless pod-promotion! Today we’re going to talk about code status, what it is, how important it is in the ER, and how you and your loved ones can make the right decision.

So, what does it mean? 

Code status indicates how aggressive a patient’s care will be in a critical situation. Full code means everything and anything will be done to try to save the person’s life, while on the other side of the spectrum, comfort measures only means that no diagnostic or curative therapies will be pursued, we are only focused on making the patient comfortable. And of course there’s a middle option here too.

Why is it called a code? Well apparently hospitals in the 1950s started using coded, as in secret, messages to alert staff to emergencies. So, on the intercom they didn’t yell, “get over here this guy is dying!” and freak out all the patients. But instead they’d say “Code Blue in room whatever.” 

That’s a code blue, when a patient goes into cardiopulmonary arrest, as in cardiac arrest they lose their pulse, or pulmonary arrest, they ain’t breathing, and this often get shortened just to the word code itself. As in you’d say, “hey there’s a code” or “that patient is coding.” And so when someone is full code, most people are of course, then resuscitating them, trying to restart their heart and take control of their breathing, is coding them or running the code. Got it?

Now the word code is applied to other emergencies you can encounter Inside the ER as well. A cardiac arrest is always a code blue, while code red means a fire, code pink usually means a baby is missing, among others. I like to say, “we got a code brown, repeat we got a code brown” when someone…uhh you you get it, you get it.

Ok so let’s get into documentation surrounding code status. You may have heard of an advanced directive or a living will. This is a legal document that you can get made that dictates what type of medical care you’d want to receive if in the future you’re unable to make decisions. It can also designate someone to make those decisions for you if you can’t, often called power of attorney or health care proxy. The advanced directive is usually about the future, what could happen, and could say something like, “If I am in a persistent vegetative state for more than 3 months then I want life sustaining treatment withdrawn.” It CAN include someone’s code status, but it might be buried in other text, or dictate a code status sometime in the future when a patient has been deemed terminally ill or something.

Instead Inside the ER we tend to rely on a form that’s completed by a health care provider as directed by the patient or their family and indicates what the code status is.

In Maryland it’s called the medical orders for life sustaining treatment or MOLST, other states say physician orders for life sustaining treatment or POLST. This form is not about the future like an advanced directive but what the patient or family wants to happen if a critical situation came up now. 

I’m going to be referencing Maryland’s MOLST form going forward, I’ll post a link to it in the show notes for your reference.  I encourage you to look up your own state’s form as well.

Ok so, the default assumption Inside the ER is that every patient is a full code, and so if someone presents in cardiac arrest, then we are running the code and doing everything to try to save their life. That would include CPR, chest compressions, medications, electricity to shock certain arrhythmias, intubation, among other procedures.

On Maryland’s MOLST this is defined as, quote: “Attempt CPR: If cardiac and/or pulmonary arrest occurs, attempt cardiopulmonary resuscitation (CPR). This will include any and all medical efforts that are indicated during arrest, including artificial ventilation and efforts to restore and/or stabilize cardiopulmonary function.”

Now if a patient is not a full code, then it can get complicated. The first main decisions in determining code status involve resuscitation (in case of cardiac arrest) or intubation (in case of respiratory arrest).

So the first, DNR, you’ve all heard it before, do not resuscitate, and this is reference to a cardiac arrest. Patients who are DNR are saying, if I lose my pulse, then I have died. Do not do chest compressions and break my ribs, let me go naturally. 

A patient that is DNI, or do not intubate, does not want to have a breathing tube stuck down their throat and put on a ventilator, even if it means that without it, they will die.

In my experience, most patients that are DNR are also DNI, and they are saying I want a natural death when it’s my time. You can be DNR but not DNI, meaning if my heart stops then it’s my time to go, but if I can’t breathe, then you can intubate me and help me recover. 

Can you be DNI but not DNR? Uhhh, not really. If your heart stops, then intubation is a standard part of your resuscitation. Sure I could mask ventilate you during the chest compressions, but this is not definitive airway management. If we get a pulse back, then what? It is not like it is on TV: Patients who go into cardiac arrest, as in lose their pulse, don’t just wake up if we get a pulse back. There’s usually unconscious afterwards and need to be intubated to stay alive.

It’s important to remember that DNR/DNI does not mean do not treat!  I’ve treated many, many patients who were DNR/DNI but otherwise wanted extensive care, and I’ve also treated patients who were DNR/DNI and wanted just limited care. Maryland’s MOLST form does a pretty good job of spelling out these options so let’s reference that.

Ok, so, if you’re not full code on the MOLST, the next option is “No CPR, Option A, Comprehensive efforts to prevent arrest: Prior to arrest, administer all medications needed to stabilize the patient. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally.” 

And below that there are two choices: 

“Option A-1, Intubate: Comprehensive efforts may include intubation and artificial ventilation.”

and

“Option A-2, Do Not Intubate (DNI):  Comprehensive efforts may include limited ventilatory support by CPAP or BIPAP, but do not intubate.” A quick aside, CPAP and BIPAP are terms for non-invasive ventilation where it’s a mask strapped to your face, as opposed to the tube down the throat.

So in Maryland a patient who is DNR-A1 doesn’t want chest compressions but is ok with intubation,  but if they’re DNR-A2, that means both DNR and DNI.

The next option on the MOLST is “No CPR, Option B, Palliative and Supportive Care: Prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use CPAP or BiPAP. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally.” So basically these patients in addition to being DNR/DNI, they want to focus mainly on comfort care and not curative measures.

It’s time for a break, we’ll be right back after a word from our sponsor.

Today’s sponsor is I, The ER Mythbuster! Are you currently a patient Inside the ER? Have you heard that a tattoo on your chest reading “DNR” will prevent CPR? Well consider this myth busted. This old yarn is complete bunk. Even a tattoo fully spelling out Do Not Resuscitate is not an official document and might make the ER staff chuckle, but will not prevent any heroic interventions. For all we know, this poor fool got the tattoo on a lark or because of a fanciful wager. If you find yourself Inside the ER and you want your wishes respected, then have bonafide documentation. 

Until next time brave patients, ER Mythbuster away!

Now, back to the show:

Why would a patient make these choices to restrict life saving care? Well, for starters, they might realize that CPR is a gruesome affair. Either with our hands or a machine, we are crunching the patient’s chest to compress it by two inches, so ribs break. We’re intubating in a chaotic scene where the patient’s airway may be full of blood or vomit. If we can’t get IV, then we’re drilling a needle into a bone and squeezing in medication that way. It’s not pretty, and usually has a slim chance of success.

Patients opting for DNR/DNI are also considering their quality of life even if we get a pulse back. If a patient is very old or sick at baseline, and has a poor quality of life, then they know that a cardiac arrest would further deteriorate that. Every second a patient’s heart’s stopped means more brain cells can die and more damage is done to their body. A lot of patients we get back never fully recover and end up suffering. So for many patients if their heart stops, then they want to die naturally. For many situations, it makes sense to me. The same with intubation, patients with already difficult medical issues do not want to get intubated and then die on a ventilator. 

This reminds me of an ICU attending I worked under as medical student in New York City. ICU docs are the masters of this, discussing code status, also called goals of care discussions. Talking with patients and families about what they want to get out of the care, are we going full bore, all the interventions, no matter how painful, or should we make them comfortable. He would always say, “Respect life and respect death,” as in respect someone’s life by treating them well, but when it’s clear that someone is dying, respect that process and let them do so with dignity and in comfort.

Moving on, the next page of the Maryland MOLST gets very granular here, stating if the patient would want mask ventilation (as opposed to a tube down the throat), blood transfusion, antibiotics, IV fluids, artificial nutrition, dialysis, or even any testing at all. The point here being that patients can make specific choices about their care, say, I want to be DNR/DNI but allow most other treatments, except I don’t want to go on dialysis. Or, I’m full code except I don’t want a blood transfusion. This stuff is pretty technical and that’s why patients need to complete this form with a medical professional. 

One thing it doesn’t mention and few of these forms do is vasopressors, or pressors, which are medications given to increase a patient’s blood pressure. Patient’s with sepsis, systemic infection, can go into shock and need pressors to survive for instance. I often find this difficult to explain to patients when deciding code status, but essentially it’s ICU level care, a form of life support. Often requiring a large catheter in the neck or groin to access the central blood vessels. So pressors, like a ventilator, are artificially life sustaining and in dire cases would mean the patient’s death if removed. So, many patients who are DNR/DNI also do not want this artificial life support.

By the way, I keep saying the patient wants this or that, but obviously there are many cases where the family is actually making these decisions. I’ll frequently encounter patients who have become demented or infirm to the point where they can not make their own decisions. So it’s up to the family to meet with the doctor and get a MOLST made. Thankfully, many of these families want to favor quality of life and opt for limited measures for their loved one.

Inside the ER you do not need a written code status or advanced directive to transition to comfort measures…if what’s being asked is reasonable.

I recently saw an unfortunate man in the ER at the end of his life from metastatic cancer. The family wanted hospice care but he was no longer able to communicate his desires. They were concerned because while he had clearly expressed his choice to be DNR/DNI and receive comfort measures only, they hadn’t filled out an official advanced directive or MOLST. Would I abide by his wishes? 

Of course! In this situation making this patient DNR/DNI and focusing on comfort measures is completely reasonable, and I filled out the form on the spot. We avoided any unnecessary testing, made him comfortable, and he passed peacefully with his family.

So, how does this apply to you or your loved ones, what should you do?

Well for starters, if everyone’s full code, then getting a MOLST made isn’t really necessary, unless you have specific requests, such as no dialysis or something. If you end up Inside the ER ill and can’t communicate, don’t worry, full code is the default and we’ll do all the things. If you’re concerned about too many interventions after a possible future event where you’re incapacitated, then consider a living will. If it’s not obvious who it would be, then designate a health care proxy or power of attorney.

If you are older or have serious chronic health problems, then you definitely need to discuss your goals of care with your family and your doctor and get something in writing. At a time of extreme stress, when the patient can’t communicate, it is a gift to the family when the patient had previously expressed their wishes and had documentation done. So, if you’re that patient, have the talk with your family and your doctor. If you don’t do it now when you’re still able, then it’ll be too late when you finally need it. Sometimes family will try to override what the patient previously decided on, and if you’re worried about that, even more reason to have a form done. 

If you’re the family broach the subject with your dad or mom or whoever, you need to have these difficult conversations now. It’s your duty to understand their wishes and follow them when the time comes, and that’s made much easier when there’s documentation. Don’t be unsupportive if your elderly or infirm family member says they want to be DNR/DNI. Everyone has to die but we can choose to do so with dignity. It’s not quitting, it’s just avoiding unnecessary suffering.

I am personally horrified at the thought of being kept alive artificially, perhaps minimally aware and perpetually in pain, all because I didn’t tell my family what I wanted and when the chips were down they thought, "we don’t know what to do, just keep him alive at all costs." I have seen many patients clearly living in mental and physical agony, ventilated through a hole in their neck, fed through a tube in their belly, but who are demented or otherwise unable to communicate and make decisions. I’m sure many of them would not want to continue living this way, but the family has the reins now, and for whatever reason, they’re not letting them go. So I’ve made my wishes abundantly clear to my family and if I live long enough that DNR/DNI makes sense then you can bet your butt I’m getting a MOLST made.

Ok so before we go, I owe you an apology. So of course before I was saying we’ll back in two weeks, we’ll be back in two weeks, but let’s be honest, I ain’t delivering, not even close. With a new baby and a new job on top of my old job, I just don’t have the bandwidth. I’m also, like, really slow at this, the scripting, recording, editing, all that, takes me forever. I did say I was amateur yes?!  So…for now, no more promises I can’t keep. I think an episode every month-ish is doable, I hope, but no promises, I’ll do my best! Maybe in the future I’ll get faster, we’ll see. Thank you again for all the support, we cracked a 1000 downloads awhile ago and it was great to see.

So if you liked the episode, please follow or subscribe or whatever, and you’ll get the next episode whenever it comes out. And while you’re at, how about leaving a review, and tell EVERYONE YOU KNOW to check us out as well. If you didn’t like the episode, feel free to keep listening as rage fuel during your workouts and tell everyone you know to do the same.

You can send in your comments and your tips on how to discuss code status with your family to insidetheer@gmail.com.

Thanks for listening and all the best.