It happens regularly and usually goes something like this: I receive a page to admit a patient to the hospital from the emergency department. I place orders and head downstairs to see the patient. I perform a history and physical exam. The patient and I discuss the likely diagnoses and plans for further workup and treatment. Before exiting, I ask a final question.
‘One question we are required to ask everyone coming into the hospital is about resuscitation. Now, I don’t anticipate that you will need resuscitating, but if for some reason your heart stops or you stop breathing, do you want us to perform CPR (cardiopulmonary resuscitation) which can include chest compressions and shocks with a defibrillator as well as placing a breathing tube and attaching it to a ventilator machine?’
Typical answers include:
- Yes, I want you to do everything.
- Yes, I’m not ready to die yet.
- Only if you think it will work.
- You can give it a try, maybe a couple of times.
- I already have a living will.
- I was asked about this last time and it’s in my records.
- No, I don’t want to be a vegetable.
- No, I’ve spoken with my family and my primary care provider, and I have chosen to be a DNR.
As you’ve probably gathered, I’m referring to a discussion about code status. A broader term for this type of conversation is called advance care planning (ACP), and it has quite a few benefits. In a systematic review of 113 publications, ACP was shown to increase compliance with patients’ end-of-life wishes and increase the quality of life for patients and their family members. ACP discussions have also demonstrated the ability to reduce medical costs without decreasing patient survival.
In this article, I want to explain what advance directives and code status are, clear up some common misconceptions, and discuss how COVID-19 influences the decision-making process so that you are prepared if you or a loved one are in need of hospitalization or have some other occasion to contemplate ACP.
What are advance directives (ADs)? ADs include a living will, durable power of attorney for healthcare (DPAHC), and physician orders for life-sustaining treatment (POLST). These are used to help medical providers understand how patients would wish to be cared for in the event they become too ill to make their own medical decisions.
A living will outlines a patient’s wishes for future medical care including CPR, ventilatory support, and artificial nutrition. Sometimes, a living will contains information about preferences on hospitalization and pain control as well as considerations for unique circumstances like dialysis or implantable defibrillators. The advantage is an objective document covering a patient’s wishes in specific scenarios. The disadvantage, however, is that it is not possible to predict every scenario, and patients sometimes find themselves in a circumstance where a living will does not apply.
Appointing a DPAHC legally assigns someone to be a patient’s surrogate decision-maker. The job of a DPAHC is to assist healthcare providers in understanding a patient’s values and wishes. Upon admission to a hospital, patients are regularly asked who they would want assisting with medical decisions in the event they become too sick to make their own choices. A surrogate can be anyone the patient chooses and does not necessarily need to be a legally-documented DPAHC. However, having an official DPAHC is particularly useful if a patient becomes incapacitated before such a conversation can occur and helps avoid disputes among family or friends who may desire to assume the role of a surrogate decision-maker.
When a patient is hospitalized, the admitting provider writes an order regarding the patient’s code status. The order is usually either ‘full code’ (attempt CPR) or ‘DNR’ (do not resuscitate). Sometimes a partial code is ordered, but this is generally discouraged because the various elements of a ‘code’ or resuscitation go hand-in-hand. For example, it wouldn’t make sense to perform chest compressions for an in-hospital cardiac arrest without administering epinephrine because they are both parts of the algorithm for resuscitation.
Living wills and DPAHCs are not physician orders. So they do not determine a patient’s code status. A POLST, however, is a physician order and is portable between facilities and often across state lines. A POLST summarizes a patient’s code status and covers other wishes like whether or not a patient would want to be hospitalized or receive artificial nutrition. A POLST can also be used, if a patient wishes, to instruct emergency medical staff not to resuscitate in the event a cardiopulmonary arrest (i.e. a patient’s heartbeat or breathing stops) occurs outside the hospital.
“Do or do not [resuscitate]. There is no try.”
— Jedi Master Yoda, Star Wars
Once a choice is made, I can’t change my mind. This is not the case. Advanced directives do not supersede the choices of a patient who has decision-making capacity. In other words, medical providers don’t go against a patient’s currently expressed wishes just because of some prior documentation.
If I undergo CPR there’s a chance I could wind up being a ‘vegetable’ on a ventilator machine for months or even years. When patients express this concern, I explain that the question of code status is about what medical providers do at the moment a patient has a cardiopulmonary arrest. What happens afterward is either up to the patient or, in the event the patient is too ill to make medical decisions, instructions from a living will, or surrogate decision-maker.
This is a prime example of the value of having a living will or appointed surrogate so that decisions about prolonged life-sustaining measures can be made with knowledge about the patient’s wishes.
The chances of recovery from in-hospital CPR are good. Despite all the available resources in the hospital, the chance of surviving and being discharged from the hospital after a cardiopulmonary arrest is only about 17%, and research shows patients tend to overestimate this number by a wide margin.
A patient would like to undergo CPR if needed but also chooses to be a DNI (do not intubate). Although there are rare exceptions, such as patients with airway abnormalities, in general, it is not a good idea to undergo CPR, which would include chest compressions, adrenaline administration, and potentially defibrillation, without being willing to be intubated (i.e. have a breathing tube placed). The reason being that after undergoing CPR a large percentage of patients are still unable to breathe on their own and may not be alert enough to protect their airway which would require intubation in order to deliver vital oxygen to the body. On the other hand, electing to undergo intubation if needed but avoid CPR is a more reasonable option that patients occasionally choose.
Whether during a pandemic or not, it’s important to understand what CPR entails. A study in 2017 showed that the percentage of patients choosing to undergo resuscitation dropped from 71% to 37% after watching a six-minute video demonstrating in-hospital CPR. Particularly for those with a terminal illness or other comorbidities that would further reduce their chances for recovery, the trauma of rib-cracking chest compressions, electrical shocks from a defibrillator, or being intubated is an ordeal patients often choose to forgo; opting, instead, for quality of life over potential quantity.
The effect of COVID-19
Caretakers are now often absent from the hospital because of visitation restrictions. This highlights the importance of discussing resuscitation and other medical directives prior to an event that would make communication difficult. The patient, family members, other caretakers, and a patient’s primary care provider are all key stakeholders to involve in such a conversation.
In light of the pandemic, many patients, including those with terminal illnesses, have chosen to remain at home. Some hospitals have created teams of expert clinicians to provide home-based assistance to these patients.
The benefit of intubation and mechanical ventilation in the setting of COVID-19 has been under scrutiny. Some studies have suggested that intubation and mechanical ventilation are less likely to reduce mortality in patients with COVID-19 compared to other respiratory viruses. While others are more optimistic about the chances of surviving such a critical condition.
In general, intubation for respiratory failure is an intervention that is only performed as a last resort when a patient would otherwise expire. Thus, I am not surprised to see a high mortality rate among patients on mechanical ventilation given that such patients are so severely ill as to require intubation in the first place. However, it is my understanding and experience that patients with COVID-19 are often able to tolerate somewhat lower levels of oxygen in the blood than providers usually prefer. So, even when standard criteria for intubation are met, there may be circumstances where avoiding intubation and its untoward consequences of pressure trauma to the lungs and additional risk of superimposed bacterial pneumonia, could potentially be valuable to the patient.
With this in mind, patients who have chosen not to be intubated can still be treated with non-invasive means of delivering supplemental oxygen, for instance by a face mask or nasal oxygen tube, and may still be receiving adequate respiratory support despite not being on a ventilator machine.
Remembering the goal
Although talking about resuscitation and other end-of-life decisions is a regular part of my job, and has, in some ways, become routine, I want to acknowledge that evaluating these issues can be difficult and far from a routine topic of conversation for patients and their loved ones.
Please keep in mind that the goal of medical care is to relieve suffering, and accomplishing this can look different for each individual. Hopefully, this story sheds light on how this goal can best be achieved in your situation.