Medical Malpractice Insights: Speaking in “Code”

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Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Editor, Med Mal Insights

“A kinder, gentler approach would benefit everyone.” Jo Stecher, RN

Emergency physicians deal with end-of-life (EOL) issues daily. According to a recent JAMA Network article, we’re pretty good at knowing when death is near. But few of us are comfortable discussing the subject with patients and their families. “Code,” “No Code,” “CPR,” “resuscitation,” etc. are buzz words that we use easily, but the lay public doesn’t have a clue.

“Allow Natural Death” (AND) is a decades-old concept beginning in the nursing literature. Physicians who use this approach are finding it to be a much better way to engage chronically ill patients being admitted – again – as their health declines and death is clearly a matter of “when,” not “if.

As you arrange the admission of your patient for the umpteenth time in the past year, the scenario goes like this: Rather than use buzz words like “No Code” or “Full Code” or any option in between, try this: “You’ve been very sick for a long time and now you’ll have to be in the hospital again. As usual, we’ll do everything we can to help you while you’re here. But what if – while you’re here in the hospital – your heart were to stop beating or your breathing stop and you died a natural death, [PAUSE for patient’s reflection] would you want us to do anything about that?”

This question reframes the whole EOL question and returns control to the patient. Eyes light up and the mood lightens as the family awaits their loved one’s response. That response is almost always “Of course not! I’ve always hoped I would die a natural death. I don’t want to die hooked up to a bunch of tubes and machines.”

This approach has worked wonders in my own practice and is encouraged by the medical directors of both our hospice and palliative care departments. They agree that the language we currently use when discussing code status isn’t doing us or our patients any favors. By using this approach, the patient’s preferences, goals and values are more easily clarified. Both specialists point out that it’s much easier for others caring for the patient to have a thoughtful conversation after we have opened the door with words patients and families can understand.

Try it. You might like it.

References:

1. Ouchi K et al. Association of Emergency Clinicians’ Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital. JAMA Netw Open, 2019;2(9):e1911139. doi:10.1001/jamanetworkopen.2019.11139 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2749777?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamanetworkopen&utm_content=wklyforyou&utm_term=09132019
2. Stecher J. VIEWPOINT: ‘Allow Natural Death’ vs. ‘Do Not Resuscitate.’ Amer J Nursing, July 2008, 108:7 https://www.nursingcenter.com/journalarticle?Article_ID=800475&Journal_ID=54030&Issue_ID=800472