Patients routinely are asked about code status upon admission, yet communication breakdowns too often occur. Expecting ethicists to sort out this important issue with every patient is, of course, unrealistic.
“But they may have an important role in the education and support of clinicians,” says Paul J. Hutchison, MD, MA, assistant professor of medicine and bioethics at Stritch School of Medicine at Loyola University Chicago in Maywood.
Ethics can accomplish this by presenting at departmental grand rounds or lunch workshops. “And for difficult conversations with patients who require additional time and attention, an ethicist is a great resource in a consultative capacity,” says Hutchison.
Of patients wanting to be full code, 10% had no orders for resuscitation, found one study.1 “The discordance signals a failure somewhere in the communication between clinicians and patients regarding code status,” says Hutchison. The finding suggests one of two things is occurring, says Hutchison:
• that conversations between clinicians and patients are not accurately captured in the medical record;
• that patient wishes are not being correctly interpreted by clinicians.
“If the latter, there is a risk that some patients’ autonomy is being compromised,” says Hutchison. These patients may not receive appropriate treatments in a life-threatening emergency.
“Ultimately, improved communication, possibly through better clinician training, could limit the amount of discordance in the future,” says Hutchison. The communication chain, ideally, includes these steps:
1. the clinician explaining code status in lay language to the patient;
2. the patient expressing understanding of code status;
3. the patient appreciating how the information applies to his or her own situation;
4. the patient making a rational decision.
“How the patient communicates the decision is essential to the clinician’s code status order,” says Hutchison.
1. Young KA, Wordingham SE, Strand JJ, et al. Discordance of patient-reported and clinician-ordered resuscitation status in patients hospitalized with acute decompensated heart failure. J Pain Symptom Manage 2017; 53(4):745-750.
• Paul J. Hutchison, MD, MA, Assistant Professor of Medicine and Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood. Phone: (708) 216-9215. Email: firstname.lastname@example.org.