Code Status:
What does it mean?
Sheila Modi
Best Practices Meeting
November 16, 2011
Objectives
 Assess current beliefs
 Define “Code Status”
 Discuss barriers to appropriate use of code status
 Discuss possible changes to our current system of discussing
and documenting code status.
Question 1
 An 80 yo F with HTN, hypothyroidism with code status
DNR comes to the ED c/o dizziness, SOB, and rapidly
deteriorating (unstable) condition. She is unable to talk
to you. Cardiac monitoring reveals SVT. Should you:
Cardiovert her.
B. Do not perform any electrical shocks, even if this results in
her death.
C. Not enough information.
A.
Question 2
 A 68 yo F with asthma and metastatic breast cancer with
a code status of DNR comes in with an asthma
exacerbation triggered by an accidental exposure to a
cat. She has impending respiratory failure. Should you:
Intubate her.
B. Do not intubate her, even if this results in her death.
C. Not enough information.
A.
Question 3
 A 75 yo M with severe COPD (FEV1 0.7) with a code status
of DNR comes in with a COPD exacerbation and has
impending respiratory failure. Should you:
Intubate him.
B. Do not intubate him, even if this results in his death.
C. Note enough information.
A.
Question 4
 A 60 yo M with HTN, DM2, and CAD with a code status of
DNR comes in with severe multi-lobar PNA and has
impending respiratory failure. Should you:
Intubate him.
B. Do not intubate him, even if this results in his death.
C. Not enough information.
A.
Question 5
 A 70 yo M with HTN, CKD, CAD, PAD, DM2, and now MRSA PNA and
bacteremia who has a documented code status of DNR is on the SAC floor being
treated with Vancomycin. Despite abx, his condition deteriorates and he develops
septic shock and respiratory distress. He is febrile 39C, hypotensive 85/55,
tachycardic 115, tachypneic 28, and his breathing is labored with accessory muscle
use. He has not responded to 3L NS. MICU (you) are called to evaluate. When you
arrive, patient’s mental status has deteriorated and he is no longer able to
coherently answer questions. Should you:
A.
B.
C.
D.
Admit to MICU, continue Vancomycin, place central line, start vasopressors, intubate and place
on mechanical ventilation.
Admit to MICU, continue Vancomycin, place central line, start vasopressors, but do not intubate.
Do not admit to MICU as patient has already indicated he does not want these aggressive
interventions, even if this results in his death.
Not enough information.
ANSWERS:
Not enough information!
Do we really know what code status
signifies?
 A survey of 3rd year medical students revealed:
 100% reported they knew what code status means
 Only 17% reported an “excellent understanding”.
 My interpretation of these findings: they didn’t really know what it
means
 Not knowing what code status means is a barrier to appropriate
use
Code Status
 Designation of whether or not to perform
resuscitation in the event of cardiac and/or
respiratory arrest.
 Code status holds NO significance in the pre-arrest period
 Should NOT influence other theraputic interventions that may be
appropriate for patient
 Other life-sustaining therapies include: intubation and mechanical
ventilation, pressors, ICU transfer, antibiotics, IV fluids, artificial nutrition
 Intubation should always be addressed separately, especially in
patients with DNR orders
 Should address the difference between intubating for respiratory insufficiency and
intubating during a cardiac arrest
Pre-arrest period
 Pre-arrest period may include failing heart and/or
ineffective breathing; and may lead to cardiac or
respiratory arrest if management fails
 Pre-arrest period scenarios include managing dysrhythmias,
ventilatory insufficiency, ineffective gas exchange, respiratory
failure
 Use of ACLS protocols is not limited to cardiac and
respiratory arrest situations; they are also used in the
management of pre-arrest conditions and adverse clinical
events.
Advance Directives
 Don’t really help much because it is often difficult to
ascertain when the wishes stated in the advance directive
apply and because the wishes indicated are at times too
vague to be useful in decision-making
 They often fail to take into account a person’s specific
medical condition
 So, it is still important to have code status discussion at
each admission
 Code status designation is valid only for single hospitalization;
should be re-addressed each time
Partial DNR orders: A hazard to patient
safety and clinical outcomes?
 The practice is clinically and ethically problematic
 Respect for patient autonomy may create the potential for
patient harm
 Medical treatments are often performed in groupings in order to
work effectively.
 When such combinations are separated as a result of patient choices,
critical elements of life-saving care may be omitted, and the patient
may receive non-beneficial or harmful treatment.
 A “slow code” is ALWAYS unethical (not intended to be theraputic so is non-
beneficial and is misleading to the decision-maker)
Partial DNR orders
 A partial DNR order highlights larger problems:
 Misunderstanding of the meaning/scope of a DNR order
 Moral hazard: providers may inadvertently withhold
treatments that are not considered part of a DNR order. This
may be inconsistent with patient preferences.
 Need for discussions around goals of care
Does DNR status affect clinical care?
 It should NOT, but studies have shown that it does.
 This is a barrier to patients choosing DNR status
 Studies have found that interpretations of what a DNR order
means vary considerably between physicians, with
implications for the overall course of treatment.
Beach, MC and Morrison RS. The Effect of Do-NotResuscitate Orders on Physician Decision Making
 A survey involving 3 hypothetical clinical vignettes involving cases
with serious life-threatening illnesses was distributed. A series of
10 sequential treatment decisions followed each vignette. Using a
4 point Likert scale, respondents were asked to indicate whether
they would initiate these interventions. There were 2 versions of
the survey, in one version the patients all had DNR orders.
 Physicians agreed or strongly agreed to initiate fewer interventions
when a DNR order was present vs. absent
•Physicians agreed to initiate fewer
interventions when DNR order in place.
•Case Mr. M: 4.2 vs 5.0 (p=.008)
•Case Mrs. T: 6.5 vs 7.1 (p=.004)
•Case Mr. H: 5.7 vs 6.2 (p=.037)
•A decrease of 1.0 on this scale
represents a 12.5% decrease in
the number of interventions that
the physicians would initiate.
•“The results support the hypothesis
that, when presented with identical
patient scenarios, physicians will
withhold treatments other than CPR
for patients with DNR orders.”
•Limitation of study: “Not enough
information” was not an option in the
survey.
Chen, J.L.T., et al. Impact of do-not-resuscitation orders
on quality of care performance measures in patients
hospitalized with acute heart failure.
 Retrospective chart review looking at HF performance measures
stratified according to the presence of DNR orders.
 HF performance measures included:
 Assessment of LV function
 Use of ACE/ARBs
 Anticoagulation (if atrial fibrillation present)
 Smoking cessation counseling
 Use of nonpharmacologic strategies, e.g. fluid restriction, diet, alcohol, and
exercise.
 Conclusion: Patients with DNR orders were less likely to receive
diagnostic and treatment therapies for HF according to the
ACC/AHA quality measure guidelines.
Code status should never be used for
broader interpretation
 Multiple studies have shown that physicians’ ability to predict
patient preferences regarding LST based on code status is no
better than chance
 We will not know unless we also ask questions about
preferences for LST
Appropriate Code Status/LST
Discussion
 Build trust, rapport
 Framed in terms of the overall goals of care
 Distinguish between LST and CPR
 Patient-specific information
 Diagnosis, treatment, prognosis
 Should educate patient on prognosis of CPR (future
slide)
 Make a recommendation
 This takes time!
Code status Discussions
 Kaldjian, L.C., et. al. Code status discussions and goals of care
among hospitalized adults.
 135 pts interviewed within 48h of admission to a general medicine service
 41 (30.4%) pts had discussed code status with their physician
 116 (85.9%) preferred Full code
 11 (8.1%) patients expressed code status preferences different from the code
status documented in their medical record.
 Most patients believed it was helpful to discuss goals of care and the chances
of surviving in-hospital CPR
 11 (8.1%) pts changed their code status after receiving information about survival
following in-hospital CPR
 2 (1.5%) pts changed their code status after discussing goals of care
Appropriate Code Status/LST
Discussion
 Build trust, rapport
 Framed in terms of the overall goals of care
 Distinguish between LST and CPR
 Patient-specific information
 Diagnosis, treatment, prognosis
 Should educate patient on prognosis of CPR
(next slide)
 Make a recommendation
 This takes time!
Prognosis after CPR
 Studies show that ~15% pts given CPR survive until hospital discharge

Although ~40% survive the initial CPR attempt
 Prognosis depends on underlying medical conditions
 One study showed that in pts with renal failure only 2% survived until discharge
 Another study showed that in pts with metastatic cancer, none survived until discharge
 With sepsis, only 1% survived until discharge
 No survivors to discharge if CPR lasted >30 min
 One study found that 11% of pts who survive initial CPR will undergo CPR at least one other
time during hospitalization
 Those who do survive to discharge usually do not have severe impairment (were AAOx3), but
all had decrease in functional status
 Of those who survive to discharge, 25% survive >5 years
 Factors for Favorable Prognosis after CPR: Healthy baseline;Younger age; Witnessed arrest;
Initial rhythm of v-fib; CPR lasted <10 min; Respiratory arrest (as opposed to cardiac arrest)
Prognosis with Partial DNR orders
 One study compared patients who received partial
resuscitation to those who received full resuscitation.
 23% (104/445 pts) who received full resuscitation survived
until discharge
 No patients who received partial resuscitation survived until
discharge (0/37 pts)
 Partial resuscitation included performing some resuscitative
measures while withholding others (24 pts)AND performing all
resuscitative efforts for a specified limited time (13 pts)
Prognosis after Mechanical Ventilation
 Many pts fear intubation b/c they are unaware of the
successful use of short-term mechanical ventilation in certain
clinical situations
 Studies suggest the most influential factor in survival to
discharge for patients with respiratory insufficiency is
presence of significant comorbidities
 One study stratified pts on Charlson Comorbidity Index: group 1
scored </= 3; group 2 scored >3
 Group 1: 94.4% were discharged home within 6 months
 Group 2: 23.4% survived until discharge
Appropriate Code Status/LST
Discussion
 Build trust, rapport
 Framed in terms of the overall goals of care
 Distinguish between LST and CPR
 Patient-specific information
 Diagnosis, treatment, prognosis
 Should educate patient on prognosis of CPR (future
slide)
 Make a recommendation
 This takes time!
Time
 Anderson, W.G, et. al. Code Status Discussions Between
Attending Hospitalist Physicians and Medical Patients at
Hospital Admission
 Observational study via audio-recordings of 80 pts admission
encounters with 27 physicians at 2 hospitals
 The median length of the code status discussion was 1 min
(range 0.2-8.2 min)
 Time constraint is a barrier to adequate discussion
Time
 Roter, D.L., et. al. Experts Practice What They Preach: A
Descriptive study of Best and Normative Practices in End-ofLife Discussions.
 Observational, audio-recordings of outpatient encounters
 Experts spent close to twice as much time (14.7 min vs 8.1
min, P<0.001)
 Experts were less verbally dominant (P<0.05)
 Experts gave less information about procedures and biomedical issues
(P<0.05)
 Experts engaged more in partnership building (P<0.05) and in more
psychosocial and lifestyle discussion (P<0.001) and in more positive talk
(P<0.05)
Time
 Loertscher, L.L., et. al. Code status discussions: agreement
between internal medicine residents and hospitalized patients.
 41 matched pairs (patients and admitting residents)
 Residents and patients agreed that a code status conversation occurred in
63% of cases
 Agreement was more likely if residents performed less than 4
admissions (P=0.02)
 Patients reported the inclusion of specific discussion components less
frequently than residents (P<0.001)
 Resuscitation procedures (pts 7% vs residents 71%)
 Outcomes (0% vs. 27%)
Time
 Deep, K.S., et. al. Discussing preferences for
cardiopulmonary resuscitation: What do resident
physicians and their hospitalized patients think was
decided?
 Resident physicians, patients + family interviewed following
discussion on code status
 56 interviews, 28 matched pairs
 In 21% (6/28 pairs), participants reported differing
results of the discussion
 2 patients did not recall having the discussion
Education
 Multiple studies show that students and residents receive
minimal education on code status and how to have the
discussion
 This is a barrier
 One study looked at 2 academic medical centers, one of
which provided education to residents about patient care
plans for patients with DNR orders
 The one with education had more comprehensive plans
 The effect of this education was sustained for 3 years after the
education was given
Review of Objectives
 Code status - defined
 Barriers to appropriate use of code status
 Don’t know definition/scope
 Partial DNR orders
 Code status has been shown to mean “less care”
 Time
 Education of students and residents
 Suggested intervention
POLST
Physician Orders for Life Sustaining Therapy
 Expands upon CPR status orders to include orders based on preferences
about a range of life-sustaining treatments
 Form has orders including:
 Code status (CPR status)
 Medical interventions
 Hospitalization
 May include antibiotic use
 Artificial nutrition
 Form is printed on brightly colored card
 This standardized medical order form transfers across care
settings
 Emergency services, hospitals, primary care practices, hospices, and
nursing facilities
POLST
 Program was developed in Oregon to overcome the
limitations of advance directives and code status
 Now also used in other states
www.polst.org
Hickman, SE, et. al. A Comparison of Methods to Communicate Treatment
Preferences in Nursing Facilities: Traditional Practices versus the Physician
Orders for Life-Sustaining Treatment Program.
 Compare POLST vs. traditional practices
 Communication of treatment preferences
 Documentation of LST orders
 Symptom assessment and management
 Use of LST
 Retrospective observational cohort study; looking at
residents in nursing facilities
Hickman SE, et. al. A Comparison of Methods to Communicate Treatment
Preferences in Nursing Facilities: Traditional Practices versus the Physician
Orders for Life-Sustaining Treatment Program.
 Results:
 Residents with POLST were more likely to have orders
about LST preferences beyond CPR than residents
without (98.0% vs 16.1%, P<0.001)
 No difference between residents with and without POLST in
symptom assessment or management
 Residents with POLST forms indicating comfort measures only
were less likely to receive medical interventions (e.g.
hospitalization) than residents with POLST forms indicating full
treatment (P=0.004) or residents with traditional DNR orders
(P<0.001) or residents with traditional Full code orders
(P<0.001).
Hickman, SE, et. al. A Comparison of Methods to Communicate Treatment
Preferences in Nursing Facilities: Traditional Practices versus the Physician
Orders for Life-Sustaining Treatment Program.
 Discussion:
 POLST orders were not associated with the use of antibiotics,
despite specific orders addressing abx use.
 These findings suggest that the use of standing orders to prospectively
make decisions about antibiotics may be an ineffective strategy, perhaps
because there is substantial variability in interpretation of when
antibiotics should be used to enhance comfort.
 Conclusion: Findings suggest that the POLST program
offers significant advantages over traditional methods to
communicate preferences about LST.
Hickman SE, et. al. Use of the Physician Orders for LifeSustaining Treatment Program in Oregon Nurstin Facilities:
Beyond Resuscitation Status
 Telephone survey and on-site POLST form review
 Oregon nursing facilities
 Results:
 71% facilities reported using POLST for at least half of their residents
 DNR orders present on 88% of POLST forms
 On forms indicating DNR, 77% reflected preferences for more than
the lowest level of treatment in at least one other category.
 On forms indicating Full code, 47% reflected preferences for less
than the highest level of treatment in at least one other category.
 The oldest old (>/= 85 yrs) were more likely than the young old (65-74 yrs) to
have orders to limit resuscitation, medical treatment, artificial nutrition and
hydration.
My Recommendations
 Implement POLST in New Mexico
 Do not include section for antibiotic use
 Provide more education to everyone
 Would be necessary in order to implement POLST anyway
 Do not allow partial DNR orders
DISCUSSION
References
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