Code discussions (this is another class paper for Narrative medicine)

 Advance Directives (ADs) delineate an individual’s health care wishes and include a Living Will (which documents preferences for CPR, mechanical ventilation, artificial feeding) and Durable Power of Attorney for Health Care. Doing a comprehensive AD discussion properly takes time and should be intermittently re-discussed.

Many individuals, unfortunately, have never had these discussions. Only about 20% of adults have ADs; the majority do not discuss goals of care (GOC) or have end-of-life discussions until they are hospitalized with a serious illness (1).

Patients with ADs have fewer hospitalizations in their last months of life and are more likely to receive care that aligns with their wishes.

Providers, in the outpatient setting, have often failed to initiate these discussions for multiple reasons.

Code status-the decision to use cardiopulmonary resuscitation (CPR)- is just one part of ADs, but ascends to one of the highest priorities when an older adult or a patient with an acute or chronic life-threatening illness presents to the ED.

In an ED study on 187 high-risk patients, or their surrogate decision makers, 84% noted to never having previously discussed code status and 83% were unaware of their current code status (2).

Therefore, unfortunately, many code status discussions take place in an ED.

Code status discussions are challenging, even for oncologists (3).

Physicians’ confidence regarding code status discussions is low compared with their confidence regarding other medical discussions (4).

It’s often a resident physician who is given the task of the code status discussion prior to admission.

In a study, 68% of residents surveyed noted not receiving any code status training during medical school and only 13% felt competent to discuss code status on their first day of residency (5). 75% noted to no formal training during residency and only 39% noted to ever having had a code status discussion observed/critiqued by a supervising physician (5).

Individuals, family members and caregivers have difficulty with code status discussions for multiple reasons (fear, guilt, distrust of the medical system, spiritual beliefs, etc.) as well misinformation regarding the success of CPR, often due to what has been depicted on television shows.

A review done in 1996 on 96 episodes of ER, Chicago Hope and Rescue 911 showed 75% were successfully resuscitated with CPR and 67% of those were discharged from the hospital (6). A more recent (2020-2011) review of 91 episodes of Gray’s Anatomy and House showed a 69.6% success rate of CPR with 71.9% of those being discharged from the hospital (7).

Actual success rate of in-hospital CPR is approximately 44% and only about 17% are ultimately still alive to be discharged from the hospital (8).

The survival-to-hospital discharge is less than 5% for older adults and those with serious illnesses (9).

Many who survive have significant neurological and functional impairments.

A standard code status question, often asked in a busy ED setting has been:

“If your heart stops, do you want us to restart it?”

It’s been equated to a mechanic asking a customer, “If your car stalls, do you want us to jumpstart the engine (10)?”

Most would say yes to questions such as this, especially in a hospital (10).

The goal of a code status discussion is to support patient self-determination and, hopefully, avoid non-beneficial interventions at the end of life (11).

The Palliative Care Network, Medical College of Wisconsin (12), offers excellent suggestions on code status discussions. Their Fast Facts encompass many Narrative-Based Medicine (NBM) principles (open ended questions, listening to the patient’s story, responding, education, etc.). After review, the following abbreviated approach could be helpful:

First state, “I’d like to talk with you about a health care choice that I review with all patients.”

And then, three questions that could potentially improve the quality of a code status discussion are:

1.      What do you understand about your current health situation?”

Transitioning to…

2.      “What are your health care goals for the future?”

And finally…

3.      “If you should die despite all our efforts, or in the event of your death, do you want heroic measures to try and bring you back?”

Using the words die or death helps to clarify the initiation of CPR is a choice that tries to reverse death (13).

The discussion can then become more specific, including actual statistics, if/when asked and/or if/when appropriate.

“Deciding to not undergo CPR does not mean that other interventions (medications, antibiotics, fluids, etc.) to treat your current condition are stopped.”

“Roughly, only about 1 out of every 6 (17%) patients who undergo in-hospital CPR survive long enough to be discharged from the hospital.”

Or for an older adult with significant co-morbidities:

“Only approximately 1 out of every 20 (5%) older adults, with medical conditions such as yours, who undergo in-hospital CPR will survive long enough to be discharged from the hospital.”

Educational efforts must continue for all health care providers and the public to discuss ADs in a non-ED setting.

Television shows are sure to continue to depict favorable outcomes to CPR.

It’s currently “Jimmy V Week” in the United States and the foundations (the V Foundation) motto is “Don’t give up, don’t ever give up.”

Therefore, discussions often need to be repeated over time as GOC change (due to changes in one’s medical condition) as well as if/when the outcome information reviewed is accepted to a greater degree.

The goal of this paper was to offer an approach for code status discussions, even in a chaotic ED setting, utilizing 3 questions that incorporate some NBM principles.

Hopefully confidence in these discussions will increase so that, ultimately, the care that is being rendered, especially to older adults with advanced chronic illnesses, will more closely align with their wishes.

References:

1.      Ram P, Horn B, Siegel A. An Internal Medicine Residents’ Perspective on End-of-life Discussions. Indian J Palliative Care. 2018, Jul-Sep: 24 (3): 388-389.

2.      Sanghvi S, et al. Decoding Code status: Assessing End of Life Care Knowledge in High-Risk Populations. The Journal of Emergency Medicine, Vol. 76, September 2025: 144.

3.      Taylor R, Gustin J, Wells-DiGregorio S. Improving Do-Not-Resuscitate Discussions: A Framework for Physicians. The Journal of Supportive Oncology. Vol. 8, No. 1, Jan/Feb 2010.

4.      Sulmasy D, Sood J, Ury W. Physicians’ confidence in discussing do not resuscitate orders with patients and surrogates. Journal of medical Ethics. Vol. 34, No. 2, Feb. 2008: 96-101.

5.      Gaffney s, Winzelberg G. When See One, Do One, Teach One Isn’t Enough: Assessing Internal Medicine Residents’ Code Status Communication Training Needs. JPSM, Vol. 59, Issue 2, Feb. 2020.

6.      Diem S, Lantos J, Tulsky J. Cardiopulmonary resuscitation on Television. Miracles and misinformation. NEJM, 1996 Jun 13: 334(24): 1578-82.

7.      Portanova J, et al. It isn’t like this on TV: Revisiting CPR survival rates depicted on popular TV shows. Resuscitation. 2015 Nov: 96: 148-50.

8.      Palliative Care Network of Wisconsin. Fast Fact #179.

9.      Palliative Care Network of Wisconsin. Fast Fact #024.

10.  Ulin L. Why so many patients are confused about CPR and do-not-resuscitate orders. First Opinion. Sept. 11, 2024.

11.  Yuen, J, Reid M, Fetters M. Hospital do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them. J Gen Intern Med. 2011 Feb 1; 26 (7): 791-797.

12.  https://palliativecarenetwork.com

13.  Palliative Care Network of Wisconsin. Fast Fact #023.