Valerie Brooke, MD
At the end of every new patient evaluation and admission to the rehabilitation hospital I have to bring up the sensitive subject of Code Status. For those of you not in healthcare, it may sound as though I am asking the patient if they know the secret password. Most look at me as though they have absolutely no idea what I’m talking about. The conversations usually go something like this.
“Mr. B, I need to ask you something that I ask every patient who is admitted here, and it has to do with your heart.”
The patient looks at me expectantly, but also with the beginnings of worry creeping into the lines in his face.
“Have you ever heard of the terms Code Status, CPR, or resuscitation?”
To which maybe about half of my patients say yes, they have heard of CPR, but they have no idea what it stands for.
“CPR stands for cardiopulmonary resuscitation,” to which he shakes his head in what appears to be partial understanding.
“The question I have is what you would want the nurses and me to do if we came into your room and found you unresponsive, not breathing, and we couldn’t find a pulse,” at which point I touched him on the carotid artery in his neck.
“Usually we would perform CPR, which includes chest compressions (I put my hands on the chest), putting a breathing tube in you (mimicking a tube going in his mouth), and then giving you medications to try and get your heart beating again.”
At this point the patient may still be looking at me in wonder, or is shaking his or her head yes or no.
“Would you want us to do that for you?” I gently ask him.
Nine times out of ten, the patient will say one of two things: “I don’t want to be a vegetable,” or “I have papers that say what I want.”
This patient’s answer is “I don’t want to be hooked up on machines forever.”
I take a deep breath and continue.
“Yes of course, no one wants to be hooked up to machines when there is no hope of recovery; and I’m glad that you have papers, which are called advanced directives, but those papers usually direct your family in what to do when there is no longer hope. I am asking you what you would want me to do in the moment that your heart is no longer beating, and you are not breathing. Would you want us to try and resuscitate you?”
“As long as I don’t become a vegetable,” is his response, to which I internally express a deep sigh.
“Well, we don’t know if the resuscitation will be successful or not.” I respond.
At this point in the conversation, there is only more confusion and concern.
“Is there something wrong with my heart?” he says in a shaky voice.
“No, it’s just that I need to know what you would want me to do if something did happen. How about I give you some information that may help you decide? Studies show that if you were to have an in hospital cardiac arrest, you have about a 50% chance of being resuscitated, but only about 7-12% of patients are well enough to leave the hospital. Most have broken ribs if the chest compressions have been done adequately, and some unfortunately have damage to their brains, depending upon how long the brain was without oxygen.”
At this point a majority of patients know what they want. “No, doctor, when it’s my time, it’s my time.” Or “Yes doctor, I don’t care if there is a 1% chance. I have grandkids I want to see grow up.” Or “I’m not sure. I want to talk to my family about this before I decide.”
Whenever my patients tell me their choice, I then ask them if they have discussed this with their families. Sadly, many have not. Which surprises me, especially when they are elderly.
So why is this conversation so important?
We once had a patient in her fifties who had a small stroke. In the middle of the night, she was found in her bed unresponsive without any pulse at all. A Code Blue was called, CPR was started, and emergency services arrived. They quickly intubated her, continued chest compressions, and took her to the hospital one block away. When her family arrived, they were upset that she was intubated. They told the staff that the patient was a DNR/DNI, do not resuscitate and do not intubate.
The patient’s wishes were not followed because she was not asked. It was assumed, because of her young age, that she would want CPR. But she did not. And then it was left to the family to ask the physicians at the hospital to remove her breathing tube. I wonder if they felt guilty. If they felt like they had ended her life.
It’s not an easy conversation to have, but it’s a necessary one.