What to do if a patient is full code (Do Not Resuscitate/Do Not Intubate) in the hospital but presents with a Physician Orders for Life-Sustaining Treatment (POLST) that indicates Do Not Resuscitate (DNR)/Do Not Intubate (DNI)?

Managing Code Status Discrepancy Between Hospital Orders and POLST

When a patient is designated as "full code" in the hospital but has a POLST indicating DNR/DNI, the hospital code status should be immediately updated to match the POLST document, as it represents the patient's most recent documented wishes regarding end-of-life care. 1

Understanding POLST Documents

POLST (Physician Orders for Life-Sustaining Treatment) forms are medical orders designed to:

• Convert patient treatment goals into actionable medical orders 1
• Ensure preferences are honored across care settings 1
• Provide explicit direction about resuscitation status and other interventions 1

Unlike advance directives, POLST forms are:

• Actual medical orders signed by a physician
• Designed to be transferable between healthcare settings
• More specific about treatment preferences

Step-by-Step Approach to Resolving the Discrepancy

1. Immediate Action: Update the hospital code status to match the POLST

   • POLST documents should be accessible to all providers across care settings 1
   • The orders should be followed as written unless there is clear evidence the patient has changed their mind

2. Verify the POLST:

   • Check that it is properly completed and signed
   • Verify it is the most recent version
   • Confirm it belongs to the correct patient

3. Assess for Changes in Patient Preferences:

   • If the patient has decision-making capacity, discuss their current wishes
   • Document any changes in preferences clearly in the medical record
   • If the patient wants to change their POLST status, facilitate completion of a new POLST form

4. If Patient Lacks Decision-Making Capacity:

   • Honor the existing POLST as it represents the patient's previously expressed wishes
   • Consult with the healthcare proxy/surrogate if one is designated
   • Document discussions in the medical record

Common Pitfalls to Avoid

• Default to "full code": Research shows that 8.1% of patients have code status preferences different from what is documented in their medical record 2
• Misinterpreting POLST forms: Studies show significant confusion exists among healthcare providers regarding POLST interpretation 3, 4
• Failing to document code status discussions: Documentation of code status discussions should be included in admission notes 5
• Not addressing the full scope of treatment preferences: POLST forms include directions about additional interventions beyond just code status 1

Special Considerations

• POLST forms may be outdated (median age of POLST in charts is 1.2 years) 5
• Discrepant full-code orders increase the potential for unwanted resuscitation 5
• Patients often overestimate survival rates after in-hospital CPR (mean estimate 60.4% vs. actual rates of 15% or less) 2, 1

Documentation Requirements

• Document the resolution of the code status discrepancy
• Include explicit instructions for specific emergency interventions 1
• Specify which interventions are to be withheld 1
• Ensure the POLST is accessible across all care settings 1

By following these steps, you can ensure that the patient's wishes regarding end-of-life care are respected while maintaining appropriate documentation and communication among the healthcare team.