Full code. Do not resuscitate. Do not intubate.

Ask anyone without a personal or family history of a hospitalization on the implication of these terms and you'd likely get a blank stare in response. Unfortunately, this incomprehension often rings true with those who need to know it most: the hospitalized patients themselves.

Many clinical reports (see here and here) have demonstrated that most physicians are not only inadequate in discussing code status with their patients but also have a tendency to avoid these discussions due to time constraints and fear of patient dissatisfaction. This lack of effective communication can result in medical mismanagement, unnecessary grief, and avoidable legal consequences.

Before I offer the reader some quick tips relating to code status, let us first review the basic definitions behind this area of medicine and the implications of being labeled as full code vs. do not resuscitate/do no intubate (DNR/DNI).

Decoding the Code

The term "code status" essentially describes what type of intervention (if any) a health care team will conduct should their patient's heart stop beating or lungs stop moving air in the event of a medical emergency.

When a patient with a full code status has an acute episode where his or her heartbeat is on the verge of stopping or has completely stopped, the health care team will often provide emergent measures in attempt to resuscitate the patient. This may involve chest compressions, electric shocks, and emergency medications that act to temporarily keep blood moving to essential organs such as the brain.

If this same patient begins to have problems breathing to the point where he or she might not be able to provide enough air movement to survive, the team will often place a tube into the lungs in order to mechanically provide enough air movement to keep them functional for a period of time. This intervention is commonly referred to as "intubation."

It is important to note that patients who come into the hospital are automatically considered full code until they either provide verbal or written instructions to not have these interventions performed on them in the event of an emergency. In this scenario, the patients' code status will switch from full code to DNR/DNI.

Below are a few important and often unrecognized considerations that patients and their families should be aware of when discussing code status with their health care team.

Five Essential Concepts to Know About Code Status

1. DNR/DNI does not imply that a medical team will do nothing in the event of a patient emergency or that the patient will get substandard care during the course of their hospitalization. Alternatively, full code does not imply that the medical team will continue futile interventions that will not benefit the patient.

2. As long as patients have capacity to do so, they are able to change their code status at any point during their hospitalization.

3. Although it is commonly not recommended, a patient may opt to have only certain interventions done in the event of a medical emergency (e.g., DNR but okay to intubate)

4. A code status discussion is considered a discussion for a reason. Because the topic of code status can be confusing to many, it is important for the patient and his or her family to ask questions and express concerns rather than passively listen and reflexively respond.

5. Patients and their families should recognize that a code status discussion is never an easy one for a physician to engage in. Although doctors may appear insensitive or awkward during this conversation, their intentions are to advocate for their patients and to practice medicine that is in line with their wishes.

Take Home Point

A code discussion is an integral part to any hospitalization. If conducted well, it will make a patient's hospital stay a much more fluid experience. If not, the lack of communication may lead to undesired patient outcomes and unnecessary distress to all involved.

Empowering the general population with a basic understanding of code status can better avoid these potential medical errors in the case of unanticipated hospitalizations.

So spread the word.

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Brian Secemsky, M.D.

Medical writing for patients, students
and practitioners.

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