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Breaking the Code

The importance of addressing end-of-life issues By Aneet Ahluwalia, MD

One of our jobs in the hospital is to address code status. From a patient’s perspective, being in the hospital is scary, and asking about what would happen if their heart stopped is sure to make it even more so. Opening the discussion can be uncomfortable for health care providers, too. But it does get easier with repetition.

Ideally, this situation should be addressed in an office with a primary care physician, allowing more time for reflection and discussion with family in a non-pressured environment. However, this is often not the case. Plus, there’s no formal way to transmit the information from outpatient to inpatient settings. Living wills and other directives as well as speaking with family members are ways to bridge the gap, but at times the question of emergent resuscitation is not addressed in these documents or discussions.

Wording is crucial in discussions—it is important to reduce the fear that arises from addressing possible death. Normalizing the situation can help, for example, by saying, “I don’t foresee this happening, but this is a question I have to ask everyone who comes into the hospital.” In addition, people may not know the difference between emergent resuscitation and prolonged life support. It often helps to ask two separate questions such as, “In an emergency, what would your wishes be…” and “If you were on a ventilator with limited chance of functional recovery…” Perhaps we should amend the way we document, discuss, and teach code discussions to include separate categories for emergent resuscitation and prolonged life support, which may make the distinction more understandable. Additional interventions that should be addressed are a feeding tube and pressors.

We should also guide our patients in these discussions since the general public has little understanding about end-of-life care and emergent resuscitation. Often, a young relatively healthy patient changes his or her status to Full Code when given a full explanation of the difference between emergent resuscitation and prolonged intubation. Obviously, we want to avoid ageism and discrimination, but we must educate our patients that being elderly with multiple medical problems, including terminal illness, entails a lower percentage chance for meaningful recovery from emergent resuscitation. We must find out patients’ priorities, their opinions on balancing quality and quantity of life, their feelings about meaningful recovery and function, what they define as suffering and what they are willing to endure, and if they have something they are looking forward to. Often, people with an increased morbidity change their decision to DNR once they are given information regarding possible recovery and the actions that can occur during a code such as intubation and CPR, which can break ribs.

These discussions can help avoid care that the family and patient may end up viewing as unhelpful and improve the quality of the end of life. In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. Their caregivers were three times as likely to suffer major depression.

As always, cost come into play. Cost is difficult to discuss when it comes to mortality, but it must be considered—25 percent of all Medicare spending is for the five percent of patients in their final year of life, and most of that money goes for care in their last couple of months. In Lacrosse, Wisconsin, there was a systematic campaign to get physicians and patients to discuss end-of-life wishes; the results were low end-of-life health care costs without sacrificing life expectancy.

Ultimately, we must arm patients with accurate, easy-to-understand information presented in a nonthreatening manner in order for them to make the best decisions for themselves. The discussion can ideally begin outside the hospital.

Dr. Aneet Ahluwalia is a third-year internal medicine resident at Northshore Evanston.

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