How do I determine the appropriate code status for a patient?

Determining Code Status: A Comprehensive Approach

The most effective approach to determining appropriate code status requires a structured conversation about the patient's values, goals of care, and prognosis, with documentation in actionable medical orders that accurately reflect the patient's wishes.

Initial Assessment Framework

When determining code status, follow this structured approach:

1. Assess Patient's Decision-Making Capacity

   • Determine if the patient can understand information about their condition
   • Evaluate if they can reason about treatment options
   • Confirm they can communicate their choices

2. Identify Appropriate Decision-Maker

   • Patient with capacity is primary decision-maker
   • For patients without capacity, identify legally designated surrogate
   • Follow hierarchy of decision-makers according to local laws if no designated surrogate

3. Review Existing Documentation

   • Check for advance directives, living wills, or POLST/similar forms
   • Note that advance directives alone are often insufficient for specific scenarios 1
   • For patients with end-stage disease, code status documentation is frequently unavailable (63% of cases) 2

Conducting the Code Status Discussion

Essential Components:

• Explore patient values and goals of care - This is significantly associated with better outcomes 3
• Discuss prognosis in clear, understandable terms
• Explain resuscitation procedures and outcomes based on the patient's condition
• Make a recommendation based on medical judgment and patient values 3
• Avoid framing code status as solely the patient's decision 3

Key Questions to Ask:

• "What is your understanding of your current medical condition?"
• "What are your goals for your medical care?"
• "What are you hoping for, and what are you worried about?"
• "Have you thought about what medical treatments you would or would not want if your condition worsens?"

Documentation and Implementation

1. Convert patient preferences into actionable medical orders

   • For patients with advanced disease or life expectancy <1 year, use POLST or similar medical order forms 1
   • POLST forms more accurately convey end-of-life preferences and are more likely to be followed than traditional advance directives 1

2. Document clearly in the medical record:

   • Full code (CPR, intubation, ICU care)
   • DNR (Do Not Resuscitate)
   • DNI (Do Not Intubate)
   • Comfort measures only
   • Limited interventions (specify)

3. Ensure accessibility of code status documentation

   • Place prominently in electronic health record (ideally "one click deep") 2
   • Include in transfer documents for patients from care facilities
   • Update regularly as patient condition changes

Special Considerations

Critically Ill Patients

• Assess clinical status using objective measures (hemodynamic stability, coagulopathy, respiratory function) 1
• Consider APACHE-II scores, which correlate with mortality and may influence code status decisions 4

Common Pitfalls to Avoid

1. Assuming DNR means limiting other care

   • DNR status does not necessarily reduce non-operative interventions 5
   • Clarify that DNR applies specifically to cardiopulmonary arrest, not other treatments

2. Failing to discuss outcomes of resuscitation

   • Less than one-third of physicians discuss resuscitation outcomes or quality of life 3
   • Patients often have different understandings of resuscitation based on their code preference:
     • DNR patients tend to view resuscitation in concrete terms emphasizing suffering
     • Full code patients often view resuscitation abstractly as "restoring life" 6

3. Not reassessing code status regularly

   • Patient preferences may change as their condition evolves
   • Code status should be reviewed after significant changes in clinical status

4. Overlooking community-dwelling patients with advanced disease

   • Patients from assisted-living and long-term care facilities are more likely to have documented code status than those living in the community 2
   • Community-dwelling patients with advanced disease are at higher risk for unwanted resuscitation

By following this structured approach, you can determine the appropriate code status that aligns with the patient's values and medical condition, ultimately prioritizing their quality of life and respecting their autonomy regarding end-of-life care.