05. Code Status

Introduction

Determine and document the code status of every patient who is admitted, particularly older adults and patients with any acute or chronic life-threatening illness. Patients with documented advanced care plans have fewer hospitalizations in their last months of life and are more likely to receive care in accordance with their wishes. Please see the family meetings section for more detailed information around goals of care discussions.

   Key Components in a Code Status Discussion

  1. Resuscitation preferences / Code status (e.g. full code, partial code, DNR/DNI)
  2. Identify a surrogate decision-maker and document their contact information 
  3. Assess the patient’s values and preferences surrounding life prolonging treatment and end-of-life care
  4. Assess preferences for invasive medical treatments (e.g. ICU level of care, surgery/procedures, pressors, artificial nutrition, IV antibiotics)
  5. Document in the medical record (e.g. ACP note, advance directive, POLST form)

The Code Status Discussion

Do not delay this discussion for critically ill patients who require emergent treatment decisions around resuscitation and end of life preferences.

 1. Prepare

  • Review the EMR for prior documentation of code status and goals of care (e.g. prior notes, advanced directive, POLST)
  • Review the patient’s medical history and current clinical condition
  • Invite an interpreter in advance if necessary

 2. Identify a surrogate decision maker

  • The patient’s verbally designated surrogate is the legal surrogate for the duration of the patient’s hospitalization
  • Consider including them in the conversation, with the patient’s permission
  • “If you were not able to make decisions about your medical care, who would you want to make them for you?”

 3. Assess if the patient has already completed any advance care planning documents (ACP)

  • “Have you talked about your wishes for emergency care if you were not able to speak for yourself?”
  • “Have you ever completed an advanced directive or POLST form? What did it say?”

 4. Discuss resuscitation/code status

  • Avoid using medical jargon. Use words such as “breathing tube” and “chest compressions”
  • If the patient is struggling with this decision, consider the following:
    • See the “Prognosis” section to guide decisions around survival and code status
    • Assess the patient’s concerns/understanding (e.g. Are they concerned that this is a permanent decision? Do they need to speak with a family member?)
    • Reiterate that the patient can change their code status. It does not need to be permanent
  • “In case of an emergency, it would help me to know your preferences for care. If you had no pulse and were not breathing, would you want the doctors to try to bring you back, or to allow a natural death? This might involve chest compressions and putting a breathing tube down your throat and connecting you to a breathing machine”

 5. Document

  • Document all information in the EMR
  • POLST forms - Complete a POLST for all patients leaving the hospital who are NOT FULL CODE (e.g. DNR/DNI, partial DNR/DNI, no ICU level of care, comfort care). Scan a copy into the medical record and provide a copy for the patient to display in their homes in case of an emergency
  • Encourage patients to complete an advance directive

     Resources:

  • Vital Talk - For communication about serious illness (vitaltalk.org)
  • Advance Directive - Guidance for patients to complete an advance directive (prepareforyourcare.org)
  • POLST (Physician Orders for Life-Sustaining Treatment): Website for patients and families with information about POLST programs by state (polst.org)