Packaging Code Status Discussions

In a recent On Being a Doctor essay in Annals of Internal Medicine (1), a cardiologist reflected on grieving the loss of her patients. As a specialist in advanced heart failure and transplantation, she had undoubtedly cared for patients whose resuscitation efforts unfortunately failed after cardiac arrest. In her essay, the author described an example in which a patient died after delayed heroic resuscitation efforts, an experience seared into her memory that molded her into becoming a better doctor.

The essay prompted me to reflect on my own experiences and perspectives about code status discussions as a medical student and soon-to-be internal medicine resident. In particular, I remember being on clinical teams that engaged patients in code status discussions at the bedside. While there was certainly variation by team and patient scenario, a common approach was to present each element of the cardiac arrest resuscitation protocol to patients separately, engaging patients in dialogue about each one as an individual intervention. In many cases, the conclusion of these discussions was to place patients under partial or modified code status: a designation to pursue some resuscitation measures but not others.

On one hand, I appreciate the efforts to convey the potential nuances of code status discussions. The intricacies of these conversations seem to reflect differences in patient preferences, as well as the wide range of potential reasons a patient might arrest and require resuscitation. On the other hand, I am reminded of the origins of the American Heart Association’s cardiac arrest resuscitation algorithm, which has been refined over time to reflect best practice guidelines since its inception in 1975. It strikes me that the resuscitation algorithm was developed and updated as a bundled “package,” including chest compressions, ventilation, and pharmacologic therapy, rather than the unbundled, menu-of-options approach I have sometimes observed clinically.

I believe that based on the principles of beneficence and nonmaleficence, a case can be made for presenting resuscitation components together as a packaged intervention to patients. Because the impact of the cardiac arrest resuscitation algorithm on patient outcomes is predicated on delivering all components together, offering only specific elements might inadvertently harm more than help. Imagine applying this approach to other treatments for conditions, such as cancer. In some instances, an acceptable benefit-to-risk ratio of surgical cancer treatment is predicated on also providing adjunctive chemotherapy or radiation in concert. In turn, not offering all components of care as a packaged intervention may undercut the overall benefit of treatment. Similarly, might there be a risk for suboptimal or even futile outcomes if only certain aspects of the resuscitation protocol are pursued in patients with cardiac arrest?

One potential concern about code status conversations focused on packaged resuscitation interventions is that they may limit patient autonomy. If anything, discussions framed this way would be highly patient centered: It is in patients’ best interests to have a shared understanding with their clinicians that chest compressions, ventilation, and pharmacologic therapy are all core elements in cardiac arrest resuscitation efforts. Patients who still prefer partial code status would make that choice with insight about the attendant limitations of achieving desired postresuscitation outcomes.

Another strategy that would likely be helpful to both patients and clinical teams is to clearly define “code status” and “resuscitation.” Thhe concept of partial code is sometimes applied to noncardiac arrest situations in which one or more components of the arrest resuscitation protocol may be indicated. For example, intubation is both a component of care during cardiac arrest resuscitation and a potential intervention in nonarrest situations, such as in patients with labored breathing or poor oxygenation secondary to underlying lung disease. In turn, a patient may desire the latter (intubation for worsening respiration) but not the former (intubation for pulseless electrical activity). Although well-intentioned, a “partial code” status that states “no CPR, intubation OK” does not necessarily capture this nuance or direct the clinical team to provide care aligned with the patient’s wishes. If anything, it could create confusion.

To be fair, as with other care interventions, the cardiac arrest resuscitation algorithm must continue to evolve over time with the emergence of new evidence, such as noncausal observational data suggesting associations between tracheal intubation during cardiopulmonary resuscitation and increased mortality compared with no intubation. However, the underlying principle remains that cardiac arrest resuscitation interventions should be offered to patients as a bundled package, and that disciplined approaches to definitions and care components can help clarify potential misunderstandings in code status discussions. Our professional ethics and commitment to patient-centeredness demand our thoughtful attention to these issues.

Reference

1. Kittleson MM. The privilege of grief. Ann Intern Med. 2018;169:729-30. [PMID: 30452577] doi:10.7326/M18-2049