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Speaking in Code
Discussions about end-of-life care should not be left for the end.
Samuel Evans, MD RES'
Each time physicians admit someone to the hospital we use a time-tested system, the history and physical, to
gather the information we need to take care of our patients. With one exception. Somewhere in that system, usually vaguely lodged within the "Social History," is one of the most important, and potentially most complex, aspects of any patient's admission: the code status.
A patient's code status is, in its most concise form, a few words that dictate his or her preferences with regard to emergency resuscitative measures. More broadly, code status is a cipher to a patient's biopsychosocial approach to life, death, and interaction with the health care system. With troublingly varied degrees of accuracy, code status reduces a patient's beliefs about goals of care, quality of life, end-of-life planning, and
surrogate decision making into a few manageable terms and acronyms: full code, DNR/DNI (do not resuscitate/ do not intubate), and CMO (comfort measures only).
Discussions about code status can be incredibly difficult for patients and physicians alike. Yet we accord little more time to this vital topic than we do to a patient's medication list or the head-to toe review of the body's systems. When a sick, distressed patient, who may not have a sophisticated grasp of his illness and prognosis, and a time-pressed house officer discuss code status, the results can border on surreal. Imagine the following encounter.
House officer: "Mr. Smith [a high school-educated 88-year-old man with oxygen-dependent chronic obstructive
pulmonary disease, in the Emergency Department in respiratory distress with his third COPD exacerbation in as many months], do you have an advanced directive or a living will?"
"A what? Never heard of it."
"Have you ever discussed with your family what you would want if your breathing were to become so bad that you needed a machine to do the work for you?"
"Nope, never came up."
"If you were to require a breathing tube and a machine to breathe for you, is that something we should do for you?"
Mr. Smith, staring blankly, shrugs shoulders: "Sure, if it'll keep me going."
"Even if it means you might never come off the machine?"
The patient who has a clear grasp of this question is the exception rather than the rule, especially in the setting
of acute illness. Mr. Smith, again staring blankly, has no answer to this. Indeed, from his perspective it seems as if I am asking, "Do you want to live?" In such a brief encounter, it is almost impossible to relay my desire not to intubate someone who may face terminal extubation.
Without any additional information from family, I would admit this patient with the fervent hope that his lungs would allow me time to get a better sense of his and his family's understanding, expectations, and possible similar experiences with loved ones. Would this situation have looked different if prior encounters with the health care system were more systematically geared toward addressing end-of-life issues? Perhaps, but for now I have a code status that I must follow, despite its woeful inadequacy to comprehensively address the complexity of his condition.
Alpert Medical School