Her name is Beatrice, an 86-year-old patient on the oncology ward at my hospital. I am standing over her body, hands on her chest, rhythmically moving up and down to pump blood from her heart to the brain and the rest of her organs -- her ribs cracking beneath my weight with each downward push. At the head of the bed, an anesthesiologist is attempting to guide a breathing tube through the mouth and into the trachea to deliver air into her lungs. I look over and see blood coming up through the tube. Almost 40 minutes passes -- several rounds of chest compressions, electrical shocks to the heart, injections of different medications, and liters of fluid transfused through IV lines -- finally, my senior resident declares that Beatrice has passed away. The monitor is turned off, the anesthesiologist stops pumping air into the lungs, and I take my hands off of Beatrice's frail body. I walk away in silence. Outside of Beatrice's room, her family, grief stricken and shocked by the traumatic events that unfolded over the past 40 minutes are told that their wife, their mother, their grandmother, has passed away.
As I walk back to take care of my other patients, I think to myself, "Beatrice should have been Do Not Resuscitate/Do Not Intubate (DNR/DNI)." However, Beatrice was Full Code, a status that was either given as a default or decided on when she was admitted into the hospital; a decision that was made either by Beatrice and/or her family members without a complete knowledge of what code status really means.
I was taught in medical school that only 18 percent of patients requiring in-hospital resuscitation efforts ultimately survived to leave the hospital; however, I was never taught how to ask a person about their code status -- in essence, if they would like to be resuscitated. By default, patients are full code unless documented otherwise. I have phrased the question in terms of: In the case your heart were to stop beating, would you want chest compressions? If you were to stop breathing, would you want a breathing tube? Do you want us to do everything we can to save you? I rarely have given patients and their families all of the information regarding what DNR/DNI or Full Code really means -- mostly because there is not enough time to do so. The majority of patients tell me that they do not want to be on life support, they do not want to become a "vegetable." I try to delineate that those decisions are for the long term, but what about in the short term, in the acute setting? This is often confusing for patients and their families. For most patients and their families that I have come across, this is the first time that they have been confronted with the question about code status. The question often seems insensitive in the acute setting of a hospital admission clouded with fear, anxiety and apprehension. Why am I asking how a patient would like to die when they came into the hospital in order to live?
On Jan. 1, 2016, under the Affordable Care Act, for the first time Medicare will reimburse physicians for advance care planning conversations with their patients. This includes discussions around end-of-life care, the process of dying, and code status. For the majority of Americans, the answer will be simple: full code. However, for those with a terminal disease or nearing the end of life, determining a code status may not be so simple. By discussing code status, its meaning and implications in a non-acute, non-hospitalized setting, I believe that the status will be determined in a way that will be respectful to and reflective of the wishes of the person. Having conversations about code status, resuscitation, and end-of-life wishes is not only about death and dying, but ultimately about what it means to have quality of life. Atul Gawande's book, Being Mortal, elegantly frames life in the form of a story, "For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens." Death is an inevitable event that will happen, and as authors of our own stories, let us attempt to write that chapter as well.
Different scenarios play out in my mind about Beatrice's situation. Instead of the default status of full code, or a code decision made in haste, without adequate knowledge, during an acute hospitalization filled with fear, anxiety, and apprehension, I imagine the code conversation happening between Beatrice, her family and her primary care physician at one or multiple office visits, with Beatrice's wishes properly documented and made known. I imagine her death from her terminal cancer to have been more comfortable, more peaceful, and surrounded by family.
During this holiday season, we should take a moment to reflect on the rich stories that make up our lives, and how we would like the last chapter of that story to be written. During gatherings with loved ones, lets talk about death and the process of dying -- not as a defeat, a failure, or an enemy, but rather, death as the next phase of life.
** Personal identifiers have been removed and altered in this article in order to protect patient confidentiality, as mandated under The Health Insurance Portability and Accountability Act (HIPPA) of 1996