Cases & Commentaries

Code Status Confusion

Spotlight Case
Commentary By Bernard Lo, MD; James A. Tulsky, MD

Case Objectives

  • Appreciate challenges of determining
    goals of care in hospitalized patients
  • Understand patients’ common
    misconceptions about CPR
  • List typical mistakes physicians make
    when discussing advanced care planning
  • Recognize steps physicians and health
    care systems can take to improve advanced care discussions

Case & Commentary: Part 1

60-year-old woman with a long history of
severe asthma without prior intubations presented to the emergency
department with shortness of breath. Her exercise tolerance had
been worsening gradually over 2 months prior to admission, with a
marked decrease in her ability to complete her activities of daily
living. On physical examination, her blood pressure was 145/85,
pulse 85, oxygen saturation of 94%, with a respiratory rate of 22.
Her lung exam was significant for diffuse-end expiratory wheezes
and decreased breath sounds at the bases. Despite having a
long-standing relationship with a primary care physician, the
patient had not designated a health care proxy or completed a
living will prior to admission.

Hospitalized patients may lose the capacity to
make medical decisions. If this occurs, hospital-based physicians
must discuss treatment decisions with a surrogate decision-maker,
and any decisions they make should be based on the patient’s
preferences.(1) These
preferences could be indicated in a written document such as an
advance directive, or in a medical record note, documenting
discussions between the patient and primary care physician.

Approximately 75% of patients who present to
hospital emergency rooms do not have an advance
directive.(2) In the
absence of a terminal diagnosis or advanced serious chronic
illness, they are even less likely to have completed such a
document. Even when completed, such documents are frequently
unavailable to physicians in the hospital. When available, they may
be difficult to interpret in the context of specific
interventions.

Ascertaining the patient’s preferences with
respect to resuscitation is particularly important. If a
cardiopulmonary arrest occurs, there is no opportunity to ask the
patient whether she wants cardiopulmonary resuscitation (CPR)
attempted. Moreover, because CPR needs to be instituted immediately
to have a chance to succeed, there is no opportunity to ask the
patient’s surrogate. On a population level, we know that 30%
of patients with serious underlying illness do not want
resuscitation attempted.(3) However, on
an individual level, physicians cannot predict patient’s
preferences regarding CPR without asking them explicitly. Thus,
hospitalists and house officers often need to discuss advance
directives with patients whom they have not previously met.

Case & Commentary: Part 2

Upon admission, the intern spoke with the
patient about code status. The patient stated that she “would
not want to be on a tube to breathe.” When asked about CPR,
she stated she did not want “shocks to the heart or pressing
on my heart.” She stated that if her breathing continued to
be this difficult and she could not live independently, she would
rather not survive. The intern interpreted these statements as
indicating the patient’s desire for do-not-resuscitate (DNR)
status, and called the resident to discuss this issue without
filling out the hospital’s DNR form.

The medical literature focuses on the concern
that patients with serious or terminal illness may inappropriately
receive CPR despite its very low success rate and its extreme
invasiveness. This case raises the opposite issue: whether patients
with highly reversible conditions refuse CPR because they fail to
appreciate how effective it is likely to be in their situation. In
either terminal illness or readily reversible conditions,
discussions between physicians and patients concerning DNR orders
and advance directives have several common features.

First, physicians often use vague language. In
this case, the patient was asked, “Would you want your life
prolonged?” without any explanation that intubation
necessitated by an asthma exacerbation is usually effective and
temporary. In other discussions, physicians may use such terms as
“very sick” or “very serious” and do not
clarify what they mean by these terms.

Second, physicians commonly use scenarios to
elicit patient preferences regarding future care. In one study of
primary care physicians discussing advance directives, 91%
presented dire scenarios.(4) For example,
doctors typically asked the patient to consider, “If you were
sick with a terminal illness ... if you had something that could
never be cured ... and you started to get really, really
sick.” In contrast, only about half of physicians presented
scenarios that involved uncertain outcomes or reversible
conditions. The reversible nature of this patient’s illness
was not discussed.

Third, physicians often miss opportunities to
address patient concerns and clarify their values. Many patients
say that they would not want life-sustaining interventions if they
had little prospect of a good quality of life. Physicians rarely
ask what constitutes an acceptable quality of life to the patient,
or what counts as a small prospect of benefit. Likewise, physicians
rarely clarify what patients mean when they say that do not want
interventions that would be a burden. This patient stated that she
valued living independently and if she could not do so, she would
rather not survive. However, there was no discussion whether she
would accept temporary dependence on mechanical ventilation in
order to regain her previous level of health. For example, the
patient could have been offered a time-limited trial of
therapy.

Fourth, when discussing CPR, physicians usually
explain the intervention in highly technical terms, without
checking whether patients understand the information.(5) Physicians
dominate these conversations speaking nearly three-fourths of the
time, giving patients little opportunity to ask questions or raise
concerns.(5) In this
case, we do not know the details of the conversation. However,
later developments indicate that the patient misunderstood the
effectiveness of mechanical ventilation in her situation.

Finally, even after discussions with physicians,
patients commonly have serious misunderstandings about
CPR.(6) In one
study, patients estimated that survival after CPR is 70%, whereas
in reality survival of CPR administered on general hospital floors
is about 10% to 15%.(6) When
patients were asked to describe CPR, 26% could identify no features
of CPR. With regard to mechanical ventilation, 37% of respondents
thought that ventilated patients could talk, 20% thought
ventilators were oxygen tanks, and 20% thought that people on
ventilators are always comatose. Thus although patients could
express clear preferences regarding whether they wanted CPR, they
often did not understand the interventions to which they were
referring. It is likely that the patient in this case envisioned
“shocks to the heart” as pre-terminal procedures and,
in contrast to many other patients, was overly pessimistic about
its success rate for her situation.

Case & Commentary: Part 3

A few hours after admission, the patient had
sudden respiratory failure leading to pulseless electrical activity
(PEA) arrest. The nurse, who did not know the patient’s code
status, called a code and CPR was initiated. The code team found
the intern’s initial assessment, which stated the
patient’s preference for no resuscitation or intubation
efforts; however, this was not corroborated by the requisite
DNR/DNI form. The resident had discussed the case briefly with the
intern (including her interpretation that the patient wished to be
a DNR), but neither the resident nor the attending had discussed
code status with the patient yet. At this point, the
patient’s blood pressure was 90/palpable with a heart rate of
40 and an O2 saturation of 92% with assisted bag-mask
ventilation.

When the patient suffered a witnessed arrest, the
team had to decide whether to implement a DNR order. During an
asthma exacerbation, there was a high probability that after
several days she would be extubated and eventually restored to her
baseline clinical condition. In ethical terms, the physicians were
concerned that forgoing CPR and intubation would violate the
principle of beneficence, which requires physicians to act for the
benefit of their patients. However, physicians also need to respect
patient autonomy, which allows competent informed patients to
refuse any intervention, even life-saving ones.(7) The implicit
ethical justification for overriding the “DNR order” in
this case is that there was substantial doubt that the
patient’s refusal of resuscitation was informed. Furthermore,
the issue had never been discussed with an attending physician, and
no DNR order was written in the medical record. The team
appropriately attempted resuscitation.

Case & Commentary: Part 4

The patient did receive cardiopulmonary
resuscitation, including medications and chest compressions. In an
effort to respect the patient’s preference to avoid invasive
ventilation, she was started on noninvasive bi-level positive
airway pressure (BIPAP) ventilation. Spontaneous respirations
returned with BIPAP and the patient was stabilized.

The following day, the patient was alert and
was able to express her thoughts about the events of the previous
night. She had not realized that intubation could be performed as a
temporizing measure. The patient thought that initiation of
intubation was synonymous with permanent respiratory support, and
stated that she thought the discussion was about whether she would
want to be kept alive if she was “a vegetable.”
Furthermore, she had not realized that resuscitation attempts could
be successful. After her experience, she stated she did want
aggressive interventions for reversible causes. Her code status was
changed to full code.

One should not over-generalize from this unusual
case. It is always possible to question whether a patient really
understands the possible (or likely) benefits of resuscitation.
However, overriding a patient’s decision should not be taken
lightly. What is ethically required is substantial doubt that the
refusal was informed, not just a theoretical concern. In more usual
cases, patients who suffer cardiopulmonary arrest in the hospital
do not have a reversible underlying condition or a good prognosis
after resuscitative measures. To override a written DNR order, the
patient should have a very high likelihood of returning to baseline
function after a short intervention.

The housestaff’s intuition when the arrest
occurred was sound: her refusal did not make sense in her
situation, and almost all patients like her would agree to
resuscitation. The real lesson here is that the housestaff should
have acted on that intuition at the time of the original discussion
about resuscitation, by engaging the patient in further discussion
to ensure her decision was truly informed.

Taking the perspective of using errors as
opportunities for quality improvement, we make the following
suggestions to physicians for discussing advance care planning with
patients:

  • Do more listening and less talking.
  • Elicit patients’ values and
    overall goals of care, and then present CPR or DNR as a way of
    matching appropriate medical treatments with these goals.
  • Use simple language to explain CPR and
    intubation.
  • Make clear the alternative to CPR is
    death, and express, quantitatively or qualitatively, the likely
    survival after CPR. If applicable, distinguish situations where the
    outcomes are better, for example resuscitation in the operating
    room or during conscious sedation for procedures.
  • Ask about preferences regarding
    scenarios with uncertain outcomes, such as successful cardiac
    resuscitation with resultant severe anoxic brain injury.
  • Assess the patient’s
    understanding, particularly if the decision is contrary to what
    would be expected in similar patients. Thus, if a patient with a
    reversible condition refuses resuscitation, the physician should
    ascertain that the patient understands that these interventions
    have a high chance of success.
  • Reassess the patient’s goals of
    care at every hospitalization.

From the point of view of improving health care
delivery systems, we make additional recommendations:

  • Standardize the DNR order sheet, with
    separate authorization for CPR, intubation, and vasopressors.
    Consider including other life-prolonging interventions (ie, tube
    feeds, antibiotics, dialysis) that may be instituted in patients
    who will not receive CPR. Remember patients generally need
    considerable guidance in these options. Be careful not to become
    too focused on the checklist.
  • Teach residents how to elicit
    patients’ preferences and arrive at goals of care.(8) Physicians
    rarely watch others discuss resuscitation and advance directives
    with patients, and trainees are seldom observed in these
    discussions by more senior physicians. To teach such communication
    skills, lectures alone are insufficient; trainees need
    opportunities to practice skills and receive feedback. Role
    playing, standardized patients, and review of videotaped interviews
    may be useful.
  • Promote interactions between
    hospital-based and primary care physicians.(9)
    Perhaps hospital-based housestaff and hospitalists should talk to
    these physicians before they write DNR or DNI orders. In this case,
    the outpatient attending physician may have said that the refusal
    was not like the patient at all and questioned whether she really
    understood the decision.

Bernard Lo, MD
Professor of Medicine
Director, Program in Medical Ethics
University of California, San Francisco
San Francisco, California

James A.
Tulsky, MD
Associate Professor of Medicine, Duke University School of
Medicine
Associate Director, Duke Institute on Care at the End of Life
Director, Program on the Medical Encounter and Palliative Care,
Durham V.A. Medical Center
Durham, North Carolina

Faculty Disclosure: Dr. Lo and Dr.
Tulsky have declared that neither they, nor any immediate member of
their family, have a financial arrangement or other relationship
with the manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, their
commentary does not include information regarding investigational
or off-label use of pharmaceutical products or medical
devices.

References

1. Lo B. Standards for decisions when patients
lack decision-making capacity. In: Lo B. Resolving ethical
dilemmas: A guide for clinicians. 2nd ed. Philadelphia: Lippincott
Williams & Wilkins; 2000:95-105.

2. Ishihara KK, Wrenn K, Wright SW, Socha CM,
Cross M. Advance directives in the emergency department: too few,
too late. Acad Emerg Med. 1996;3:50-3.[ go to PubMed ]

3. Hofmann JC, Wenger NS, Davis RB, et al.
Patient preferences for communication with physicians about
end-of-life decisions. SUPPORT Investigators. Study to understand
prognoses and preference for outcomes and risks of treatment. Ann
Intern Med. 1997;127:1-12.[ go to PubMed ]

4. Tulsky JA, Fischer GS, Rose MR, Arnold RM.
Opening the black box: how do physicians communicate about advance
directives. Ann Intern Med. 1998;129:441-449.[ go to PubMed ]

5. Tulsky JA, Chesney MA, Lo B. How do medical
residents discuss resuscitation with patients? J Gen Intern Med.
1995;10:436-442.[ go to PubMed ]

6. Fischer GS, Tulsky JA, Rose MR, Siminoff LA,
Arnold RM. Patient knowledge and physician predications of
treatment preferences after discussions of advance directives. J
Gen Intern Med. 1998;13:447-454.[ go to PubMed ]

7. Lo B. Promoting the patient’s best
interests. In: Lo B. Resolving ethical dilemmas: A guide for
clinicians. (2nd ed.) Philadelphia: Lippincott Williams &
Wilkins, 2000:30-41.

8. Tulsky JA, Chesney MA, Lo B. See one, do one,
teach one? Housestaff experience discussing do-not-resuscitate
orders. Arch Intern Med. 1996;156:1285-1289.[ go to PubMed ]

9. Lo B. Ethical and policy implications of the
hospitalist system. Am J Med. 2001;111:48-52.[ go to PubMed ]