Wednesday, April 20, 2005

Know Your Code Status

What is code status?

Anyone admitted to the hospital has a code status. It tells us what you want to have done if you suddenly stop breathing or your heart stops beating (what is referred to in hospitals as a "code blue"). Kind of like everyone is innocent until proven guilty - everyone is assumed to be a full-code unless we're told otherwise. It is not the same as an advanced directive. A code status only provides very basic information; it does not address the finer points of whether or not you'd want a feeding tube or to be left breathing dependently on a respirator for years.

Full-code: This means you want us to do everything and anything humanly and technologically possible to keep you alive.

DNR/DNI: why isn't it called "Allow natural death?" DO NOT resucitate. DO NOT intubate. Those words are so negative. But in the case of someone who is terminally ill, natural death is much more peaceful and beautiful than having a tube thrust down your throat, ribs broken during the chest compressions of CPR, and electrical shocks shooting through your body during defibrillation.

Are there other options with "codes"?

Anyone can pick and choose between each act that may be performed during a code. Some people may want to be intubated if they have a sense they may die from difficullty breathing, but feel they would want to live even if they had to be on a respirator, at least temporarily. Some people may be aware that they have very little time left and would thus prefer to die naturally rather than gain a few extra days spent uncomfortably on a respirator, unable to talk.

What are the different components of a code?

Before going into the components, I want to acknowledge a few points. I think it is very important for medicine to be demystified, so that the general public can make informed decisions about their health. But I don't want individuals to get totally caught up in the fine details. I am making this information avaiable and as easily comprehensible as possible. But if you are terminally ill, please do not get so caught up in contemplating each component of a code status that you don't do what is most important - live now - and attend to the more important decisions, questions such as - how are my relationships with my loved ones? That said, here are some of the details that may or may not be necessary should you stop breathing or your heart stop beating:

-CPR - this link provides a nice and brief summary of the pros and cons of going through CPR (which can include chest compressions and/or having air blown into your lungs artificially using a bag or machine or as in the case of community CPR, someone breathing into your mouth)

-vasopressors and antiarrhythmics are medications that go through your veins to get your heart to return to a regular rhythm. These are the least invasive of the measures used in a code, so simultaneously the most likely options patients consider keeping when not wanting to forego all of the "heroic measures" of a code.

-intubation is when a tube is inserted through your mouth into your trachea to provide an open airway so you can breathe. Oxygen is usually administered through the tube, as well as gaseous medication or anesthetics. You re not able to speak when you are intubated. And usually you remain intubated until it is believed you can maintain your own airway and breathe on your own (usually days). Unfortunately, sometimes people are intubated and placed on respirators and are not ever able to breathe on their own again. This is when family are faced with the tremendously difficult task of deciding whether or not to turn off the respirator.

-tracheostomy is when a temporary or permanent hole is cut into your throat (trachea or windpipe) through which you then breathe

-defibrillation is when an electric shock is sent to your heart to return it to a normal rhythm. Defibrillators are now part of standard CPR training and the devices exist in many public places such as airports. So if your heart stops beating in an airport, where they will not know your code status, you will likely undergo defibrillation.

-transcutaneous pacemaker is when pads are applied to your chest that send electrical impulses that keep your heart beating in a regular rhythm

-pacemaker via transvenous/epicardial wire is when a wire is inserted through your vein and into your heart to keep your heart beaating in a regular rhythm

-chest tube may be inserted through your rib cage or back to drain blood, air or fluid from around your lungs

Is DNR/DNI the same as hospice or palliative care?
No. Code status does not address the plan for your care. You can receive a full armory of treatments to cure or halt the progression of your disease while having a DNR/DNI code status. Again, this simply tells us - if you stop breathing or your heart stops beating, what you want us to do.

Do you need to be a DNR/DNI in order to enroll in hospice or palliative care?
Definitely not for palliative care. The code status requirements for hospices vary among each facility. If you are interested in hospice, but are not ready to forego heroic measures if you stop breathing or your heart stops beating tomorrow, call around. You should be able to find a hospice that will allow you to remain a full-code for the time being.

Really, code status is a very personal decision that only you can decide for yourself. But I hope some of this information helps you should you need to make this decision in the future - I hope it will be an informed decision.

This link on code status provides a comprehensive discussion on the importance of discussing code status with patients. It was written with medical professionalsl as the intended audience but also provides excellent information for the general public.

And again, don't forget to write your advanced directive and living will no matter how healthy and young you may be today!


Anonymous said...

Thank you for sharing this information. You have helped me reconcile memories in my life about my grandmother, who died when I was very young. I'm writing a book about the family history, and one of the more difficult moments to write about is what happens in one's very last breaths of life. Your perspective has enabled me to understand what has taken place in the past, as well as prepare for difficult decisions in the future.

Anonymous said...

Do you know what a no core means?