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Must We Discuss Code Status?

February 25, 2018
by Mark David Siegel

Hi everyone,

One of the first studies I joined as a faculty member in the mid-1990s was a multicenter project exploring how patients died in American MICUs. The goal was to document how many patients were “full code” when they died, how many were DNR (resuscitation withheld), how many had life sustaining treatments withheld, how many had therapy withdrawn, and how many were brain dead.  It turned out that only a minority died full code- most deaths followed decisions to limit treatment.  This finding represented a major change from the past, when it was unusual to stop or withhold interventions- for example to stop dialysis or extubate- before a patient died.

I wasn’t particularly surprised by these findings, which reflected our experience at Yale.  Far more surprising was how much variation there was between hospitals: In one hospital, almost 80% of deaths followed a decision to withdraw treatment, but in some places, treatment was never withdrawn. The unfortunate implication was that the care dying patients received depended on where they were admitted to, not their prognosis or treatment preferences.  Related studies showed other surprising sources of variability, like the doctor’s religion, who was on call, and whether ICU beds were available.

I also learned that terminology varies a lot between hospitals. For example, what would you call it if you decide to forgo chest compressions when a patient on five vasopressors finally loses his pulse? Is that patient “DNR?”  Do you need to seek the family’s permission to hold compressions?  Do you have to enter a DNR order first?  For the purpose of the study, would the patient’s death be deemed “full code” or “DNR?”

I thought about this study this weekend when one of our cirrhosis patients went into septic shock with systolic pressures in the 50s despite maximal doses of norepinephrine, vasopressin, phenylephrine, dopamine and epinephrine. The same questions arose.  Did we have to do chest compressions when she lost her pulse?  Should we ask the family for their thoughts?  Could we just decide unilaterally to withhold compressions?  If so, did we need to enter a DNR order?

What would you do? Sloane, Alex, Dasha, and Samir know what we did (so don’t ask them), but I’m curious what you would do. Tell me what you think and I’ll circle back to the end of this story next week. 

For now it’s back to the MICU.

Mark

Submitted by Mark David Siegel on February 25, 2018