Talking in Code: Difficulties of the Code Status Discussion

“He can’t be DNR … that’s not what he wants … he must not have understood … he should be full code!” About two thirds of the way through my palliative medicine fellowship, I was moonlighting on the oncology floor and, in the middle of the night, a patient’s daughter had called about her father’s change in code status earlier in the day. This was a great example of how, even as someone who should feel comfortable with this discussion, it can be challenging to address this issue in the middle of the night. Time, however, is not the only barrier to having these sorts of conversations.

One might expect that after 3 years of internal medicine residency and 1 year of palliative medicine fellowship that I would feel completely comfortable talking about code status. Yet, despite a lot of practice working toward developing this skill, I still do not feel I have it quite figured out. As the In the Clinic article on palliative care from Annals of Internal Medicine points out, both patients and physicians are nervous about having these sorts of conversations. For me, the difficult thing about having this conversation was that I knew it would involve appropriately responding to the daughter’s emotion (which takes time and energy!) as well as trying to discover what her father’s goals are. One of the most essential lessons I have taken from my fellowship training is to learn about my patient’s everyday goals, such as being able to keep gardening, walk around with their grandchild, or cook a favorite meal, and then use that knowledge to make recommendations about which medical procedures (including resuscitation) do and do not make sense to achieve these goals. Regarding CPR, a palliative care attending once explained, “No patient wants to be resuscitated. What he or she wants is to be able to live a quality of life that is acceptable to them.”

This practice of learning about someone’s goals takes time, and even if you ask the right questions, few patients have ready-made responses. I perused the note of my patient and found documentation of a decision to change the code status based on the likely clinical outcomes for the patient given his poor prognosis and delirium, but unfortunately, his goals (or what his family felt they would be) were not explicitly stated. Obtaining this sort of information is important, but so is documenting it clearly in case of situations just like this.

When I’m trying to learn about a patient’s goals, I might ask questions such as “Given your current illness, what is most important to you?” or “What is most important for you to be able to keep doing?” Ultimately, we want to provide clinical recommendations that match these goals. The In the Clinic palliative care article lays out a step-by-step approach to achieve this. In essence, the process starts by ensuring patient understanding of the current clinical scenario, eliciting their goals for treatment, and then tailoring your medical recommendations to those everyday goals.

Though I was not able to get to this place with the delirious patient on the oncology floor and did not have the time to have the full conversation with his daughter, there have been other times where asking about everyday goals have proved quite helpful. When I was admitting an older gentleman with heart failure, I asked what was most important to be able to keep doing. He replied, “Being able to move around, cook, and communicate with my grandkids.” Other times, patients are confused about what you could possibly be asking. This is where I give examples and particularly focus on what activities patients want to be able to do from a functional standpoint and then move toward other less easily measurable goals such as “having quality time with my family.”

Knowing your patient’s everyday goals is gold. This allows for true informed consent. Rather than laying the burden of deciding whether a procedure (such as CPR or intubation) makes sense at the patient’s feet, we can discuss the impact of that procedure on the patient in a way that makes sense to them. In other words, try not to ask, “Do you want us to try to bring you back if we can?” As I continue to ask about code status, I will always try to keep in mind: “everyday goals first.” While not every patient will readily tell us what is important—for those who already have thought about it—it does not necessarily take long to find out.

Reference

1. Swetz KM, Kamal AH. Palliative care. Ann Intern Med. 2018;168:ITC33-ITC48. [PMID: 29507970] doi:10.7326/AITC201803060