From the Guidelines
The best practice for addressing a patient's code status prior to discharge is to have a clear, documented discussion about their preferences for resuscitation and end-of-life care, as recommended by the American Heart Association in 2013 1. When addressing a patient's code status, it is essential to consider their values, goals, and quality of life preferences. The following steps can be taken:
- Initiate the conversation early in the hospital stay, ideally not on the day of discharge, to allow patients to consider their options and make informed decisions without pressure.
- Use plain language to explain what code status means, including full code, DNR (Do Not Resuscitate), and DNI (Do Not Intubate) options, as well as the probability of surviving in-hospital cardiac arrest, as patients, especially older ones, can understand prognostic information and make decisions based on it 1.
- Discuss the patient's preferences and ensure that advance directives, living wills, and durable power of attorney for health care are in place to guide care when the patient is unable to make decisions on their own.
- Document the discussion and decision in the medical record, and complete any necessary forms, such as POLST (Physician Orders for Life-Sustaining Treatment) or state-specific advance directive documents.
- Ensure the decided code status is clearly communicated to the patient, family, and receiving care team, and provide the patient with a copy of their code status documentation to keep with them. This approach is supported by the American Heart Association's 2013 consensus recommendations, which emphasize the importance of advance planning and patient-centered care in ensuring that patient preferences guide care, even when the patient is unable to make decisions on their own 1.
From the Research
Best Practices for Addressing Code Status
- Code status discussions are essential for understanding patients' preferences in the case of a cardiac/pulmonary arrest and providing a basis for informed decision-making regarding life-sustaining treatment 2.
- A majority of patients do not report having discussed code status during their hospital stay, and physicians frequently omit such discussions, potentially failing to attend to patients' preferences for care 2.
- Physician training regarding code status discussions may improve the quality of informed decision-making and patient-centered care 2.
Approaches to Code Status Discussions
- Ending code status discussions with a question or a recommendation did not impact do-not-resuscitate (DNR) choice or perception of physician compassion, suggesting that both approaches are clinically appropriate 3.
- Patients who chose DNR for themselves and most patients who did not choose DNR for themselves chose DNR for a video patient, indicating that patients' preferences for code status may be influenced by various factors 3.
Code Status Reconciliation
- Code status reconciliation (CSR) is critical in ensuring that patients' end-of-life wishes are honored, particularly at transitions of care 4.
- Electronic health record (EHR) enabled CSR is effective in improving the identification and documentation of code status, representing a significant informatics opportunity to enhance care quality and patient safety 4.
Patient Preferences and Knowledge
- Patients' resuscitation preferences, knowledge of cardiopulmonary resuscitation (CPR), and goals of care are essential aspects of code status discussions 5.
- Patients' mean estimate of survival to discharge after CPR was 60.4%, and most patients believed it was helpful to discuss goals of care and the chances of surviving in-hospital CPR 5.
Role of Specialized Nursing Teams
- Employing a focused nursing team to conduct code status, goals of care, and advance health care planning conversations may be an effective use of time and resources, resulting in de-escalation of resuscitation orders for patients demonstrating illness or geriatric syndrome 6.
- Specialized nursing teams can provide meaningful support for patients and families, decrease provider burden, and facilitate code status changes at discharge 6.