Common misconceptions and mistakes
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Advising your patients to avoid resuscitation based on your assessment of the severity of their baseline cardiopulmonary disease and your “certainty” that resuscitation attempts would fail or that extubation would be impossible
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Accepting a do not attempt resuscitation (DNAR)/do not intubate (DNI) , full care code status without specific elaboration regarding the desired interventions for sudden ineffective breathing (ie, change to comfort care vs possibly uncomfortable noninvasive ventilation attempts)
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Accepting a DNAR/DNI status from a patient without significant chronic disease, daily limitation, or suffering (without vigorously investigating and presuming patient misunderstanding)
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Accepting a split code status request (ie, cardiopulmonary resuscitation (CPR) okay, but DNI) without vigorously investigating and presuming misunderstanding
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Offering advanced care for an exact period of time (eg, 48 hours or 7 days)
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Confusing therapeutic electricity (ie, shocking a symptomatic supraventricular tachycardia [SVT]) with resuscitation
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Asking a patient if he or she “wants to be intubated,” failing to mention the alternative (ie, death)
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Believing that once a code status is established, it should not be changed
Approach to code status
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Patients should only be offered one of four possible code statuses:
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Full code, full care
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Full care, DNAR/DNI
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No escalation of care, DNAR/DNI
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Comfort as the primary goal, DNAR/DNI
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Establishing the appropriate code status:
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Full code/full care:
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The majority of individuals seeking medical attention for an acute illness will accept all critical care interventions, assuming:
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They can be returned to their preillness state of health and functional status
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They will not have to suffer
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Therefore the majority of patients admitted to the Intensive Care Unit (ICU) should be full code, full care
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Full care, DNAR/DNI:
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Only a minority of individuals will want to pursue full care without resuscitation attempts:
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Typically these are individuals with a lot of daily suffering and/or significant physical or cognitive limitation who are “ ready to die ” comfortably if things go poorly or unexpectedly
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It is imperative that full care, DNI patients understand that sudden respiratory compromise is typically uncomfortable and requires immediate intervention, either:
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Noninvasive ventilatory support (ie, bag valve mask [BMV], oral airway, bilevel positive airway pressure [BiPAP]), which is also uncomfortable or
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Change to comfort as the primary goal with immediate administration of narcotics and benzodiazepines, initiating a comfortable death (that often ensues quickly)
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Patients unhappy to pursue a comfortable (often rapid) death in the setting of sudden respiratory compromise must reconsider their code status and are probably more appropriately full code, full care
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Specifically clarify that intubation does not equal ventilator dependence under any circumstances
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Remind patients that once placed on a ventilator, they (or their surrogate) can decide “enough is enough,” choosing compassionate extubation followed by a controlled, comfortable death (at any point)
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Full care, DNAR/DNI patients should be offered all possible interventions (unless specifically discussed), assuming they have a pulse:
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Electrical cardioversion for symptomatic tachyarrhythmias
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Atropine and/or pacing for symptomatic bradycardia
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BMV and BiPAP
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No escalation of care, DNAR/DNI:
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No escalation of care can be considered in a few circumstances , where “comfort as the primary goal” is the most appropriate code status, but :
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Loved ones are en route to pay final respects
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The surrogate must feel and express that the patient would want to wait
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The patient must not be suffering
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Deterioration has occurred quickly and the family/surrogate need a little more time to process the information
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The patient and/or family are “waiting for a miracle”
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Poor prognosis, further escalation of care futile, but family and/or patient are not ready to change focus to comfort, often because of the sudden unbelievable nature of the catastrophe (eg, drug-induced fulminant hepatic failure in a nontransplant candidate)
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Comfort as the primary goal, DNAR/DNI:
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Most appropriate when death is imminent and unavoidable or if the patient is ready to die and wishes no further intervention (may be expressed by the surrogate)
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Compassionate extubation must be a part of changing to comfort as the primary goal
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Intubation is not comfortable
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Patients should be extubated to room air
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Postextubation oxygen supplementation does not provide comfort and instead may needlessly slow an anticipated death
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Splitting resuscitation attempts makes no sense:
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CPR okay, but DNI implies either:
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Patient misunderstanding regarding intubation (usually equating it with ventilator dependence)
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The doctor’s inappropriate certainty that once intubated the patient will never be extubated
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No CPR, but okay to intubate implies that either:
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The patient has been threatened by the brutal nature of CPR (“I don’t want broken ribs”)
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The doctor is inappropriately certain that CPR would be futile
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No CPR, DNI, chemical code only implies that:
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The doctor lacks understanding about the circulatory system (pointless to give medication to a nonperfusing patient in the absence of CPR)
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Do not:
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Advise your patients on code status decisions based on your assessment of the severity of their underlying cardiopulmonary disease and your “certainty” that intervention would be futile (eg, FEV 1 < 1 L will never get off the ventilator, EF of 10% will never survive CPR)
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You will remember all those “certainties” in the coming years as you see other patients defy all your best previous predictions, and you will wonder, “maybe I shouldn’t have talked that guy out of intubation, or that gal out of CPR”
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Threaten patients with body defiling, rib cracking CPR
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Makes no sense (broken ribs are bad, but death is worse) and makes the resuscitation team sound awful
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Aggressive attempts to avoid CPR should only be made when cardiac arrest is imminent and untreatable (as occurs in refractory acidosis or hypoxemia)
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The argument to the surrogate should be based on the futile nature of CPR in the specific clinical setting (with a clear explanation [ie, “the low oxygen levels are not survivable”])
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Offer advanced care for an exact period of time (eg, 48 hours or 7 days)
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Life and death decisions must not be arbitrary
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Very unsatisfying (and untenable) to withdraw care if someone is making significant progress but then “runs out of time!?”
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Instead, focus on a short (days to a week) or moderate duration (weeks) vs prolonged support
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This strategy (appropriately) errs on the side of life
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Use of the term “withdrawal of care” sounds terrible, and it is not true; instead use “focus on comfort”
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Code status may appropriately change several times throughout an individual’s illness and/or ICU stay based on their clinical course; for example:
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A patient may be made DNAR because of a refractory hypoxemia and a falling PaO 2 (and the futility that this implies should cardiac arrest occur), only to be changed back to full code if they miraculously improve
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A patient with a terminal illness who is dying at home on home hospice DNAR/DNI, which practically means no 911 call from home, may wish to be full code when he or she is admitted to the hospital with pulmonary edema, accepting short-term aggressive care with hopes of returning home to die
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