The "Code Status" Conversation

Kyle P. Edmonds, MDAssistant Clinical Professor

Doris A. Howell Palliative Care Consultation Service

UCSD Health System Ethics Committee

THE “CODE STATUS” CONVERSATION:

EVIDENCE AND GUIDELINES

• List one reality of CPR.

• What are the guidelines for the code conversation?

• Name a positive and negative prognostic factor for a patient status post CPR.

• What was the likelihood of survival for patients with a “partial” code?

OBJECTIVES

TIMELINE

• Elam, Safar & Gordon demonstrate CPR techniques in a surgical populationMid-1950s

• AMA recommends documentation of code status1974

• First hospital policies drafted1976• President’s Commission on Bioethics

Guidelines (still standing)1983• Patient Self Determination Act1990• AMA CEJA Report on End-of-Life Decision

Making (still standing)1991

THE USUAL

“I need to ask you some questions that we ask all patients who are very sick. These questions are about CPR, or cardiopulmonary

resuscitation. I need to know your preferences.

“If your hearts stops beating, do you want us to use electrical shocks and chest compressions to try to get your heart beating

again? Or if you stop breathing, do you want us to put a tube down your throat into your lungs and attach you to a breathing machine

to help you breathe?”

Ref: Balaban, 2000.

INADEQUACIES OF THE USUAL

• Lack of empathy

• No discussion of prognosis

• Treats it as an “informed choice” conversation without offering all the information

• Do you frame CPR as “normal”?

“Normally, if someone’s heart stops…”

• Do you ever use “shock talk”?

“We smash on your chest and break your ribs…stick a tube in your throat…”

VARIATIONS ON THE USUAL

ROSOW’S DECISION MATRIX

Patient

FamilyProvider

• TV survival and discharge rate = 67%

PATIENT EXPECTATIONS

• 37% did not want code status discussion

• Less likely to want if:

• Older

• More functionally impaired

• No partner

• BUT: 5 times more likely if conversation perceived as relevant

PATIENT EXPECTATIONS

Heyland et al, 2006

PATIENT EXPECTATIONS: MEANING MAKING

Johnson et al., 2011.

• 27% eventually requiring CPR judged stable at admit

• CPR conversation less likely to be documented on:

• Direct admissions

• Surgical admissions

• Hospital transfers

PROVIDER EXPECTATIONS

Mirza et al., 2005

• More likely to have documented discussion:

• Older

• White

• More educated

• Residing in care facility

• Hospitalized in last 12 months

• Difficulties with ADLs/iADLs

PROVIDER EXPECTATIONS

Auerbach et al, 2008

“The experiences of our participants indicate that residents primarily adopt a model of informed choice in their discussions

about life-sustaining treatment...in employing this approach, what may actually be a value-laden medical decision is camouflaged as

a depersonalized, hypothetical...” – Deep et al, 2008

• “Mandatory Autonomy”

• Pt Role: decide

• Doc Role:

• Provide info

• Execute Decision

…PROVIDER EXPECTATIONS: INFORMED CONSENT

REALITY OF CPR: BY THE NUMBERS

30% of in-hospital arrests (3000)

40% develop

ROC (1200)

1% live to discharge

(12)

25% live to 5 years

(3)

Loertscher et al, 2010

• AHA Ethical Guidelines list goals of resuscitation:

• Preserve life

• Restore health

• Relieve suffering

• Limit disability

• Respect the individual

• The guidelines specify the role of patient autonomy

REALITY OF CPR: GUIDELINES

REALITY OF CPR: CONSCIOUS AWARENESS?...

101 Participants

No Memories (54%) Memories (46%)

Memories, no NDE, no recall

(33%)

Memories, NDE, no recall (9%)

Memories, NDE, Recall (2%)

Parnia et al, 2014

• Memories (46%)• Fear

• Animals & plans

• A bright light

• Violence / persecution

• Déjà vu

• Seeing family

• Recalling post-code events

• NDEs (9%)

• Explicit intra-code recall (2%, 1 unverified, 1 “verified”)

…CONSCIOUS AWARENESS?

Parnia et al, 2014

GUIDELINES

Unchanged from 1983…

• Begin with a discussion of prognosis and general values, goals and preferences;

• Discuss CPR as an intervention including likelihood, risks, benefits and outcomes; check for comprehension;

• Physician makes a recommendation consistent with the patient’s values and goals as discussed previously.

• (For GME: Replication of discussion by attending if (1) DNR status or (2) high likelihood of patient requiring CPR)

“Discussions that do not include the recommended elements yield, at best, a decision for full code, the default without a discussion. At

worst, brief discussions may reinforce misinformation about the effectiveness of CPR which may negatively impact future

discussions.” –Anderson et al, 2010

GUIDELINES




• Categorize : Low or high risk

• Eliminate distractions

• Patient comfort level

• Who is this PERSON?

• Patient’s understanding (Dx, Px)

UNDERSTAND THE PATIENT

Adapted from: Loertscher et al, 2010

GUIDELINES




WHEN THE USUAL DOESN’T WORK

Goals of

CareAlive Code

StatusDead

A BRIEF ASIDE ON “GOALS OF CARE”

Goals of Care

Hopes

Fears

Values

Code Status

Patient/Family Us

• Emphasize routineness

• “If you were to die while here in the hospital…”

• Describe CPR as a package

PROVIDE CONTEXT


• Age >70

• Sepsis

• Metastatic cancer

• ESLD or ESRD

• GI Bleeding

• Healthy baseline

• Younger age

• Witnessed arrest

• Initial cardiac rhythm = VFib

• CPR duration <10 minutes

• Respiratory arrest (rather than cardiac)

…PROVIDE CONTEXT: PROGNOSIS

Favorable Poor

Adapted from Mirza et al, 2005 & Loertscher et al, 2010

GUIDELINES




• Offer recommendation based on:

• Condition (“medically appropriate”)

• Goals/priorities

• “We want to do anything we can to help you live longer and better, but CPR in our opinion would only hurt you, so I don’t recommend it.”

• Clarify you will never abandon

• Develop a plan based on the discussion

OWN YOUR DEGREE


• Document

• Who was there?

• Context

• Patient/Family goals & values

• Your medical recommendation & if you shared it

• Outcome

THE FINE PRINT: PROOF OF THE CONVERSATION

GUIDELINES




• Ethical recommendations:

• Should not preclude aggressive pre-arrest care

• Should not preclude ICU care

• May not preclude short term ventilator support

THE FINE PRINT: PRE-ARREST MANAGEMENT

• Overall survival to discharge: 15-23%

• Survival for those with partial code status:

0%

“Choosing to include or exclude one element of a larger combination of treatments may

inadvertently prevent what otherwise would be a successful resuscitation.”

THE FINE PRINT: “PARTIAL” STATUS

Sanders et al, 2011

• Guide your planning to wean from a vent

• Use of the Charlson Comorbidity Index to stratify:

• Score ≤ 3 : 94.4% success

• Score > 3 : 23.4% success

THE FINE PRINT: “SHORT TERM” VENTILATION

• 67 yoM with widely metastatic lung CA

• Poor oral intake

• Admission Dx: ARF

• Wishes to remain full code

CLINICAL SCENARIO ONE


• 82 yoF with DM and CKD who has a POLST listing DNAR status

• p/w Afib with RVR

• Elects for cardioversion

• Is this okay? Do you rescind the DNAR?

CLINICAL SCENARIO TWO


• 73 yoF w/ metastatic colon CA in hospice w/ severe abd pain LBO

• Rec: palliative diverting colostomy

• Wants to maintain DNAR during surgery

• Surgical team wants DNAR suspended

CLINICAL SCENARIO THREE

CONCLUSION

• AHA Ethical Guidelines list goals of resuscitation:

• Preserve life

• Restore health

• Relieve suffering

• Limit disability

• Respect the individual

• Guidelines in establishing code status:

• Discuss prognosis & goals of care

• Discuss CPR as an intervention to revive

• Provide your recommendation

• (Document!)

CONCLUSION

Kyle P. Edmonds, [email protected]

THE “CODE STATUS” CONVERSATION:

EVIDENCE AND GUIDELINES

REFERENCES• Anderson, Wendy G., Rebecca Chase, Steven Z. Pantilat, James A. Tulsky, and Andrew D.

Auerbach. "Code Status Discussions between Attending Hospitalist Physicians and Medical Patients at Hospital Admission." Journal of General Internal Medicine (2010): 1-8. Web. 10 Jan. 2011. <springerlink.com>.

• Auerbach AD, Katz R, Pantilat SZ, et al. Factors associated with discussion of care plans and code status at the time of hospital admission: results from the Multicenter Hospitalist Study. J Hosp Med. 2008;3(6):437–45.

• Back, A. L., R. M. Arnold, W. F. Baile, K. A. Fryer-Edwards, S. C. Alexander, G. E. Barley, T. A. Gooley, and J. A. Tulsky. "Efficacy of Communication Skills Training for Giving Bad News and Discussing Transitions to Palliative Care." Archives of Internal Medicine 167.5 (2007): 453-60. Print.

• Balaban, Richard B. "A Physician's Guide to Talking about End-of-life Care." Journal of General Internal Medicine 15 (2000): 195-200. Print.

• Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987). A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis, 40(5): 373-383.

REFERENCES• Cotter, P. E., M. Simon, and S. T. O'Keeffe. "Changing Attitudes to Cardiopulmonary Resuscitation

in Older People: A 15-year Follow-up Study." Age and Ageing 38 (2009): 200-05. Print.

• Council on Ethical and Judicial Affairs, American Medical Association: Guidelines for the appropriate use of do-not-resuscitate orders. JAMA 1991; 265:1868–1871.

• De Vos, Rien, Rudolph W. Koster, Rob J. De Haan, Hans Oosting, Poll A. Van Der Wouw, and Angela J. Lampe-Schoenmaeckers. "In-hospital Cardiopulmonary Resuscitation: Pre-arrest Morbidity and Outcome." Archives of Internal Medicine 159 (1999): 845-50. Print.

• Deep, Kristy S., Charles H. Griffith, and John F. Wilson. "Communication and Decision Making about Life-sustaining Treatment: Examining the Experiences of Resident Physicians and Seriously-ill Hospitalized Patients." Journal of General Internal Medicine 23.11 (2008): 1877-882. Print.

• Ebell MH, Kruse JA: A proposed model for the cost of cardiopulmonary resuscitation. Med Care. 1994; 32(6): 640-649.

• Heyland, D. K., Chris Frank, Dianne Groll, Deb Pinchora, Peter Dodek, Graeme Rocker, and Amiram Gafni. "Understanding Cardiopulmonary Resuscitation Decision Making: Perspectives of Seriously Ill Hospitalized Patients and Family Members." Chest 130.2 (2006): 419-28. Web. 10 Jan. 2011. <http://chestjournal.chestpubs.org/content/130/2/419.full.html>.

http://chestjournal.chestpubs.org/content/130/2/419.full.html

REFERENCES• Kass-Bartelmes BL, Hughes R, Rutherford MK. Advance care planning: preferences for care at the end of

life. Rockville (MD): Agency for Healthcare Research and Quality; 2003. Research in Action Issue #12. AHRQ Pub No. 03-0018.

• Loertscher, Laura, Darcy A. Reed, Michael P. Bannon, and Paul S. Mueller. "Cardiopulmonary Resuscitation and Do-no-resuscitate Orders: A Guide for Clinicians." American Journal of Medicine 123 (2010): 4-9. Print.

• Mirza A, Kad R, Ellison NM. Cardiopulmonary resuscitation is not addressed in the admitting medical records for the majority of patients who undergo CPR in the hospital. Am J Hosp Palliat Care. 2005;22(1):20–5.

• Morrison, Laurie J., Gerald Kierzek, Douglas S. Diekema, Michael R. Sayre, Scott M. Silvers, Ahamed H. Idris, and Mary E. Mancini. "Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care."Circulation 122 (suppl 3) (2010): S665-675. Web. 10 Jan. 2011. <circ.ahajournals.org>.

• Parnia S, Spearpoint K et al. (2014). AWARE-AWAreness during Resuscitation: A prospective study. Resuscitation. ePub ahead of print.

• Prigerson HG. Socialization to dying: social determinants of death acknowledgement and treatment among terminally ill geriatric patients. J Health Soc Behav. 1992;33(4):378–95

REFERENCES

• Sanders, Alan, Melissa Schepp, and Marianne Baird. "Partial Do-not-resuscitate Orders: a Hazard to Patient Safety and Clinical Outcomes?" Critical Care Medicine 39.1 (2011): 14-18. Print.

• Smith, Alexander K., Angela P. Ries, Baohui Zhang, James A. Tulsky, Holly G. Prigerson, and Susan D. Block. "Resident Approaches to Advance Care Planning on the Day of Hospital Admission." Archives of Internal Medicine 166.15 (2006): 1597-602. Print.

The "Code Status" Conversation

Health & Medicine

Transcript of The "Code Status" Conversation