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…..”