Code Status

The concept of code status is something very familiar to most of my medical collegues, as well as anyone who has worked in a hospital and has heard the unfortunate “Code Blue” anouncement over the loudspeaker. Or anyone who has watched any of the current medical dramas on TV for that matter. Code status is basically what a patient would like the doctors to do if there was an unfortunate event while in the hospital, if the patient should stop breathing, or if the heart should stop. Try to bring the patient back to life, or not? If we don’t know the code status of the patient, we do everything possible, and in less than 10% of the time, this attempt at CPR (cardiopulmonary resusitation) is successful, but much less so if that patient is very ill, has cancer, or is already in the ICU. And it’s nothing like they show on TV.

As interns we are expected to ask every patient that we admit about their code status. Doesn’t matter how old they are, how sick, or why they were admitted to the hospital. We put the status in their chart, so that everyone can easily look in the case of an emergency and know what the patient wants. If the patient is not competent to make that decision, due to mental illness or brain injury, then it’s up to their family or whoever they have previously appointed their power of attorney, to tell us what the patient would have wanted.

My training in how to have these conversations about code status has been next to nil. I do vaguely remember at my medical school being shown how to fill out a code status form (called the POLST – physican’s orders for life sustaining treatment), which in addition to having little check boxes for chest compressions and intubation, also had boxes for tube feeds, dialysis, antibiotics, intravenous fluids, or comfort measures only. I never got to hear a doctor ask a patient these questions, to learn from someone more experienced. No one has guided me in how to discuss these issues with family members who want to keep their loved ones alive no matter what.

I have learned the difference between DNR/DNI (do not resusiate, do not intubate) and CMO (comfort measures only – when someone is terminal and you only provide care for comfort, no heroic life saving measures). I have learned that doctors and families alike are not comfortable having these discussions, to the point that there is a whole sub-speciality called Palliative Care, whom we often consult in the hospital for help with these code status and end of life discussions. I have learned that I myself am not comfortable with these conversations, not because I am afraid of the subject of code status and death, but because I am so inexperienced when it comes to the end of life.

I remember in medical school on my rural rotation watching a 90 something year old woman struggle to breath. Her family had decided to stop treatment, and just make her comfortable. She wasn’t even conscious in the end. I waited outside her room, until the family called me in to tell me she had passed. I listened to her silent heart and lungs, checked her pupils, and confirmed her death. I remember another woman on my internal medicine rotation that a “code blue” was called on. The nurse had found her dead in her hospital bed. We rushed to the room and did chest compressions, intubations, and medicines for 45 minutes, all to no avail. I remember another woman in my ICU rotation who had end stage liver disease and was also unconscious. Her family decided to detach her from the ventilator. We pulled the tube out and waited for her to pass. It took about 30 minutes before her breathing finally stopped, and another 5 minutes for her heart to stop beating. Another woman down the hall, also with end stage liver disease, was also removed from her ventilator by the family, but she took over 24 hours to pass. That’s about all the experience I have with death. So how am I supposed to advise patients and families about what the end of life will be like? What to expect? How long the patient has left? These are all questions I cannot answer.

So far in residency I have not been around many dying patients. But I have been taking care of many patients that are near the end of their lives, with cancer, end stage kidney disease, old age, dementia, failure to thrive, and so discussions of life and death are part of my every day. I am learning by fire. By being thrown into sticky situations – and just making it up as I go, but with one thing in my mind and heart: What is in the best interest of the patient, and what will cause the least amount of suffering. Sounds easy to do, but is actually challenging and exhausting. As much as I love taking care of sick patients, I am really looking forward to July 1st, when I can switch over to physical medicine and rehabiliation, where patients are much more stable, and the chances of them dying under my care much more slim. But I will still get to ask them the now all too familar code status questions: “What would you like us to do if…..”

 

5 Comments

  • Ronando wrote:

    You’re a great doctor Valerie. I wish all doctors had your compassion for the sick and elderly and desire to do right for the patient.

  • Andrea wrote:

    Thank you for writing! I just came across your blog on the internet today. It is exactly what I was looking for. In fact I decided that if I went to medical school I would document my daily trials as you have to provide for everyone else what I couldn’t seem to find! The only thing I wish you would include more of (and perhaps you have and I just haven’t read this yet-though I intend to read every post) is the challenges of maintaining a personal life. That is my biggest fear above all is losing myself and my family. I currently work 12-17 hour shifts at the hospital so I get working a long shift but I want to know just how grueling the schedule is for med school and residency. I hear horrific stories about 80 hour weeks but is this continuous through residency or an over-exaggeration? Oh one more request- please continue this blog once you complete your training. I want to see how people change and if it becomes easier once you begin practicing in your field. I want to see if there is regret or boredom, if the hours are still long and treacherous… Yep just requests from a stranger but it never hurts to ask right? lol Thanks again for what you have already written! You are well written and like I said, it’s exactly what I was looking for to help me make my final decision: become an anesthesiologist or become an anesthesiologist assistant…

  • Valerie Brooke wrote:

    Hi there! So glad you found and like the blog. Yes medicine is incredibily time consuming, and I have to admit that there are days that I ask myself why I made this choice, especially later in life. You can have work/life balance though, but you have to make boundaries for when you are going to stop working/studying, and when you are going to take care of yourself. I’ve never worked more than 80 hrs in residency so far, and usually it’s spaced out between a harder month, then an easier month. I have no regrets, but there are definitely things that I do not have the time to do, and these things will have to wait for retirement. But I love the patients, and I love the constant learning, as well as the challenges that make medicine what it is today. It is SO MUCH more than medical knowledge. There are so many social skills that are necessary to survive. If you’re not a people person, than medicine is definitely NOT for you. Good luck!

  • Ricki Orton wrote:

    Hi Valerie,

    I check your blog every couple of weeks to see if uou have a new post! Checked today and there it was, I was very excited because I have learned so much from you. You are very well written and I enjoy every moment. I know you are very busy and its hard to blog more often. But please never quit blogging. Thid is very helpful to those of us who want to enter the medical field and lets us know you got through med school and are getting through the end of your training. I will hopefully be starting school in the Fall at a community college and taking care of all my prerequisites and then on to pre-med and med school! Continue to stay focused and good luck on everything to come! 🙂 Thanks!

  • Valerie Brooke wrote:

    Thanks for the encouragement Ricki, and so glad you are getting something from my writings. Good luck in your studies. One step, one class at a time and you will get there! I remember my post-bac pre-reqs, and it seems like so long ago! Thanks to you also for your support!

Leave a Reply

Your email is never shared.Required fields are marked *