The Code Status Conversation -- Do It Before It's Too Late

When working at the emergency department, residents usually sign up for acuity levels 1-3, unless level 4 or 5 is a pediatric patient. I would choose any level for the kids. On that day, I chose a level 3 with a chief complaint of "back pain." Soon after my initials appeared next to the patient's name, one of our nurses walked into the doctors' work room and said, "Doc, your patient is desaturating to 60% on room air."

It is probably safe to assume that we all know what was wrong with the patient. I expected the presentation and I assumed the primary diagnosis. What I did not know was the "discussion" I would have with my patient upon first meeting him.

Wearing full PPE — gown, gloves, and what I nicknamed my Darth Vader mask (a gas mask I usually carry inside my The New Yorker tote bag) — I walked toward my patient's room.

When I first saw him, I asked him to prone (adult tummy time), which is one of the least invasive ways to effectively help folks with COVID breathe. We were getting the BiPaP machine. All of the alarms were going off, and his O2 was too low at 15 L nasal cannula O2 supplementation. His heart was beating too fast and irregularly. His eyes bulged as he gasped for air, and there I was, asking whether, in the event that his heart stops working and his lungs stop breathing, he'd like chest compressions and a tube down his throat.

My experience was far from unique. His experience, unfortunately, was not unique either. I felt the need to ask not just because of impending respiratory failure but also because I knew that I was likely the only native Spanish-speaking physician he'd meet during his stay.

Code status discussions should not take place in the emergency room.

Palliative care doctors are highly trained to conduct this kind of conversation.

Critical care doctors have had to learn how to hold these conversations as well. The truth is that all physicians should at least know the basics on how to conduct such important discussions.

Setting

The ideal code conversation will take place with the patient's family and long-term primary care doctor. Similar to the checkbox for colon cancer screenings, one for code status/goals of care discussion should pop up as part of the Health Care Maintenance tab. This would be ideal for all patients, but especially for those age 65 or older or those diagnosed with a terminal illness.

Once the patient is admitted to the hospital, you can still work to optimize the environment:

1. Set a meeting time

   • Most patients will have friends or family that would like to be present for such conversations. It's okay if some family members meet over the phone.

2. Sit down

   • Grab chairs for everyone who will be participating.

3. Lead with compassion

   • No one wants to be in this situation, but at the same time, the meeting is to discuss hope for improvement in quality of life and empowerment for the patient.

4. Normalize the discussion

   • If possible, note that this topic is brought up with every hospitalized patient, regardless of disease severity.

5. Find common ground

   • You can ask what they have heard about code status, goals of care, and end-of-life wishes if they are at that point. Ask about any questions they may have in advance.

6. Normalize, partner, reassure

   • Our society does not promote, as a whole, having these kinds of discussions.

   • We want to fulfill the patient's wishes and provide the best care possible.

   • Although they are not always ready to discuss end-of-life care, many times the patient and family will want to know the doctor's recommendation.

7. Explain concepts

   • What do we mean by "resuscitate"?

   • Does this mean we will stop all treatment?

8. Explain next steps

   • You may not reach a conclusion at this meeting and will probably ask these questions again.

9. Communication

   • Fill out a POLST if possible.

   • Make sure the team is aware of new status if anything changes and that it is added to the tabs.

Although not ubiquitously taught as part of the medical education curriculum, end-of-life discussions need to be part of our standard of care and will free the patient and their family from guilt and stress during some of the most difficult moments of their lives.

For more information, see this resource, which is also available as the app Fast Facts.

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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: Jemma Alarcón. The Code Status Conversation -- Do It Before It's Too Late - Medscape - Dec 07, 2021.