Resuscitation Status

Resuscitation Status

Full Code vs DNR / DNI

Resuscitation or “Code Status” is very important. It communicates not only to the hospital staff but your friends and family your wishes should your heart stop or your breathing worsen to the point that without intubation and being put in a ventilator death would follow. 

Detailed information from Virginia Department of Health and forms available here. 

Full Code – this means if you heart stops you want CPR, defibrillation (“shocking”) in an attempt to restart the heart beating. You also desire intubation and ventilation (breathing tube put into lungs and hooked to a ventilator to breath for you). This is the presumed default status for anyone without a defined resuscitation status. 

Do Not Resuscitate / Do Not Intubate (DNR/DNI) – this means when your heart stops on its own you DO NOT WISH staff to perform CPR, shock the heart, intubate and put you on a ventilator and keep your alive. Classically people referred to this as “being kept alive by machines.” 

This is NOT the same thing as an advanced directive. While an advanced directive often discusses this and makes wishes known they are two separate forms. Most advanced directives have language stating that artificial means of keeping them alive be withheld in futile situations. 

A code status is the direction for staff to immediately act or not act when sometimes heart or breathing fails. As a doctor if I walk into the room and find someone without a heart beat I’m not going to walk down the hall to go read several pages of his advanced directive to determine what I should do. Immediate direction and a decision are needed; either begin CPR and intuition or don’t; this is why a Code Status exist. 

Some common misconceptions influencing one’s thoughts on Code Status:

  1. DNR / DNI means Do Not Treat (FALSE) – staff continue to treat someone with the same medical care to improve their health. DNR/DNI do not come into play until the heart or lungs have stopped functioning. 
  2. CPR will “fix them” – CPR does nothing to fix the medical condition which led to cardiac arrest. If one has advanced cancer, dementia, COPD, heart disease, recurrent aspiration, etc CPR as a best case scenario brings someone back long enough for them to suffer cardiac arrest again by the same condition. A dying body leading to the heart stopping is just that, a dying body, CPR does not change this.
    1. Brain damage starts to set in after a few minutes with significant brain damage expected after 6-10 mins. 
    2. 30% of people who survive after CPR have clinically significant disability and about 10% of severe disability.
  3. You shock someone when they “flat line” to restart the heart. This is Hollywood fantasy. A “flat line” heart (asystole) CANNOT be shocked. 
  4. CPR has a high rate of success. (FALSE) – Again a TV myth.
    1. On TV people survive CPR about 75% of the time. OUT-OF-HOSPITAL CARDIAC ARREST SURVIVAL IS 7 – 9%; If they get bystander-initiated CPR goes to 10-12%.
    2. CPR in a hospital will save me: in-hospital CPR survival: 40-50% may survive initial CPR attempt, but only 17% survive to be discharged from the hospital.
    3. Rates of survival are the same for everyone (FALSE) – like all other medical conditions the older and sicker you are the more likely things will not go well.
      1. A study in Sweden found that survival after out-of-hospital CPR dropped from 6.7% for patients in their 70s to just 2.4% for those over 90. Chronic illness matters too. One study found that less than 2% of patients with cancer or heart, lung, or liver disease were resuscitated with CPR and survived for six months.
      2. I would expect the average Swede to be healthier than the average American too. 
      3. Dice example: chance of rolling any number on 1 die: 16.6%. Change of rolling 2 dice the same number (“snake eyes”): 2.7%. So someone in their 90s surviving CPR to leave the hospital is the same as snake eyes. 
  5. There is nothing to lose so why not try? Common thought process. However; CPR when done usually breaks ribs. Also most people are intubated during CPR and placed on a ventilator. This means should you beat the odds and survive you will likely awaken on a ventilator trying to breath with the pain of broken ribs.
    1. Many times I’ve seen futile CPR done at the direction of the family who aren’t ready to let go only to see the person survive and suffer in agony struggling to breath until the same process stops their heart again. These situations are always tragic. The family’s emotional distress was treated by CPR which in turn created more time for the patient to suffer before death. 

What should you do about your Code Status?

Take a critical objective look at yourself or your family member. Ask yourself the following questions:

  1. How old are you? Are you “good” for your age or frail and debilitated?
  2. How is your overall health? Generally in good healthy are mostly sick?
  3. Do you have a medical condition which only gets worth until death? Example: advanced cancer, dementia, heart disease, heart failure, COPD, aspiration, kidney disease if not on dialysis. 
  4. Given the realistic probabilities of surviving, have pain from broken ribs and surviving without brain damage do you desire to have CPR?
  5. MAKE YOU WISHES KNOWN IN WRITING. 
    1. Fill out a Durable DNR
    2. Tell your family and your medical team your wishes so there is no confusion.
      1. This is a hard but very important conversation with family members. It recognizes the inevitability of death. It should be clear to family members they are to respect the patient’s wishes. More than once I’ve had a patient, who was DNR/DNI arrest and the family members are in a panic screaming “Save her, do everything!” and now the choice is to abide by the patient’s wishes (what should happen) or give into the screaming family member (what usually happens). 

Recommendation for families trying to decide a loved one’s wishes. 

So often there is no Advanced Directive, Code Status, or any discussion prior to the patient approaching death. At this end-of-life stage the family is left to try and make a decision for what the patient would have wanted. Here are some tips:

  1. Ask yourself: “If the patient could stand next to their own bedside and tell you what they wanted what would they say? If you know immediately the answer then the choice is made.
  2. Ask yourself if placed in the patient’s situation yourself what would you want?
  3. Often families know the patient would never want advanced aggressive therapy at the end-of-life but feel they are “giving up” on the person. Abiding by the wishes of the patient is never “giving up;” it is honoring their independence and right to self determination. Everyone should be respected in how they would choose to leave this world. Even if it is at odds with those who loved them most. 
  4. I tell patient’s families my duty as a physician is the wishes of my patient, not their families. We should all be honored in this manner.