How to discuss Code Status and make a recommendation
Perelman School of Medicine at the University of Pennsylvania
Code status discussions are often rushed events done during a hospital admission by a doctor that the patient has never met. The content, and therefore the quality, of these discussions varies widely and often contains very incomplete information that fails to meet a person at their individual health literacy level. Additionally, once a physician decides to make a recommendation for a DNR status, the methods used may be crude and border on coercive.
The goal of this lecture is to provide the listener with a complete understanding of CPR outcomes that can be presented flexibly at the level of the health literacy of the patient and family. Second, the lecture provides a framework for making a recommendation of CPR by not viewing it soley as a health literacy problem but as a fit between a patient's stated values and the likely outcomes of CPR. In this way, there are many reasons why a person may choose to be DNR.
First, an evidence review of outcomes are discussed by site of care (inpatient, outpatient and nursing home) including immediate failure, prolonged death in a hospital, survival with impaired neurological status and survival with intact neurological status. Both absolute and relative rates are presented. An evidence review of the risks are summarized including the trauma of CPR, what happens when a person fails to survive to hospital discharge and surviving with impaired neurological status. Success rates in studies are analyzed by diagnosis, age, and functional baseline. Finally, how to translate the outcomes into goals and values is discussed including when being DNR is appropriate for a patient. Ideally, the learner will have more tools for helping a patient understand why DNR may be appropriate than before this educational session.
The purpose of this lecture is to allow the listener to have a much more complete understanding of the pros and cons of CPR and its outcomes and have a framework for making recommendations. The goal is to move beyond simply thinking about the trauma and success rates of a procedure-oriented CPR discussion and move towards a value-based, patient-centered discussion.
The power point lecture is accompanied by a handout that serves as a literature review. There is also a bibliography. In a small group setting, the handout could be the starting point of an interactive discussion. I usually start by asking the housestaff and students when they have felt a patient who was full code should be DNR, why they felt that way, and how they went about trying to change the code status. I ask what they communicate and how they communicate it. Having learners provide their own vignettes gets them more engaged in the discussion and at the end they can think about what they might have done differently.