No Code, Slow Code, 45 Minute (Purgatory) Code: Responsibility and Accountability in Attempted Resuscitation from Death

Physicians can abdicate their responsibilities as reasoned guides for patients making decisions at the end of life and as gatekeepers of resuscitation practices in many ways:

• By failing to address "Code Status" at all, letting patients be "Full Code" by default (and by failing to work as a profession to reconsider or change the default)
• By asking, in a matter-of-fact manner, "if your heart stops, do you want us to do CPR to try to restart it" without discussing the probability of success and the likely outcomes, both immediate and longer term, in the (often unlikely) event of success
• By failing to probe the reasons why a code status election that is at odds with their (and/or the nurses') judgment has been made; i.e., taking for granted the legitimacy of a Full Code declaration when doing CPR will clearly or likely be futile
• By discussing the issue of code status solely from an agnostic position, as though there is no right or wrong election, when in fact the physician has a strong belief about what is appropriate and what is not (such as Full Code nonagenarians, elderly patients with hemorrhagic stroke, those on the ventilator with multisystem organ failure, those with metastatic cancer, etc.)
• By defaulting to a Slow Code as a dissimulating compromise for the conflict between the documented code order and their sense of what is medically appropriate
• And the topic of this post:  by conducting a 45 minute code without reevaluating, during that time interval, the premises upon which the Code Blue was initiated, and without integrating the new information that accrues during the resuscitation attempt

Use Your Own Judgment: The Feckless Physician, the Tyranny of Autonomy, and the Courage of Convictions

All too often as an intensivist I am called upon to evaluate/treat a patient who is "Full Code" but who is utterly moribund.  My moral fiber is shredded by  the thought of instituting critical care measures in a poor, frail,weak, malnourished and cachexic, demented and derlirious nonagenarian (or octogenarian, or septuagenarian) with incurable disease.  So, it would be morally corrupt to acquiesce to the "Full Code" order and proceed as an  insentient automaton and put such a patient on life support, knowing that nothing good, and a good deal bad will come of it.  "A cog in the wheel" as it were.

Something strange and tragic is going on here:  While my physician colleagues are most often in consensus about the likely outcomes and the perceived futility (or net harm) of medical care in these cases (as are other informed medical personnel), they often do acquiesce to the "Full Code" order, and initiate the self-perpetuating sequence of futile treatments, disappointments, and indignities inflicted upon dying patients.  This disconnect has two possible explanations:

1. Patients' values and preferences are vastly divergent from those of their physicians and other informed healthcare providers; or
2. Patients and their families have not been properly informed about the prognosis, likely outcomes, and burdens of care.  (If denial is involved, this still counts as improper information - as with alcoholism and addiction, physicians have a duty to break down denial.)

So, does my moral repugnance at the thought of taking the moribund nonagenarian, giving him propofol to ablate his consciousness for (probably) the remainder of his natural life; inserting a tube through his vocal cords and thus making it impossible for him to speak; knowing that he's delirious/demented and has little hope of knowing what's going on and is probably in fear or distress; physically tying down his hands to the bed so that when he reacts instinctively to pull out the tube that is gagging and choking him, he cannot; inserting various other tubes and medical devices into his nose, urethra, anus, mouth, and through skin incisions into various other bodily structures; performing CPR and having my fellow healthcare workers feel and hear the breaking of his ribs and sternum; knowing that this poor patient will never leave a healthcare institution and return home - does this moral abhorrence derive from a set of values that I have about life and humanity that are divergent from those of the patient and his family?  Or does it result because I have different information about what these procedures entail and what their effect is likely to be?  (That effect candidly amounts to torture.  I am being asked to torture the poor fellow.)

The answer is obvious because people are more alike than they are different.  I have an abhorrence to these acts because I (and other informed healthcare workers) understand them better than the patients/families - there is "asymmetrical information" as economists would say.  Why would this be?

This results because of the "feckless physician" - the squeamish nebbish who believes that guarding the family (and himself - especially himself) from a vivid description of futile (and harmful) care at the end of life and the emotional reactions consequent to this discussion are more important than avoiding the horrors of actually delivering that "care" and inflicting that suffering on the inexorably dying.  And here I will state it:  the feckless physician, in making this choice, is morally corrupt.

He rationalizes this away by invoking the misguided principle of autonomy - the notion that people should be able to make choices for themselves.  But this ethical principle has certain premises and preconditions, and it is easy to pretend that they have been met - namely that the preconditions of information and understanding have been met.

So, when the patient (or, often his surrogates) is/are making choices such as "Full Code" that seem at odds with his moral intuitions and common sense, the feckless physician deludes himself into believing that he has imparted the requisite information about the procedures and likely outcomes in an adequate manner, and he acquiesces.  He is satisfied to invoke the foundationally precarious principle of autonomy to justify the indignities that are about to befall the poor, dying, nonagenarian.

And he calls the intensivist.

"It'll break her ribs": Checking boxes on the Code Blue Sushi Menu

For more reasons than I wish to enumerate here, the discussions of death and dying that physicians are having with patients at the end of life are so simplistic, myopic, confused, and lacking in nuance that they resemble a theater of the absurd.

The implications for individual patient care and health care in general are weighty indeed, but I will defer their statement to other commentators or other posts.  Herein, I review some of the absurd elements of the approaches I often see used to broach the topic of decision making at the end of life, and offer some (admittedly vague) suggestions about how this sorry state of affairs can be improved upon.

Let us begin with what has been called the "Chinese Menu" for "Code Status".  I prefer to call it a Sushi Menu.  I should pause to explain terminology.  When a patient dies in the hospital (we have various euphemisms for death in the hospital - "passing", "coding", "full arrest" [curiously, there is no "partial arrest"], etc. - but the key point which we must confront directly - not tangentially - is that people do eventually die) a "Code Blue" is called overhead.  Code blue called overhead on the hospital PA system activates a team of various hospital employees of sundry disciplines, who respond and attempt to resuscitate him.  A patient's "Code Status" is medical jargon that signals to that team what the patient wants them to do in the event that they die in the hospital. In the simplest of its various forms Code Status is dichotomized to either "Full Code" meaning the patient has directed the team to "do everything" that is reasonable to resuscitate him; or to "DNR/DNI" which means Do Not Resuscitate/Do Not Intubate - that is, do not intervene and allow the patient to die naturally in the event that they stop breathing or their heart stops.  Why would a patient choose to die naturally rather than be resuscitated?  Because often being resuscitated forestalls death only for a short time during which the patient cannot communicate or get his affairs in order - time that has little value and may increase the net burden of suffering, all of it in the hospital in a state of questionable consciousness, connected to machines and being poked and prodded and "run through the ringer" until death inevitably intervenes.  As a sage friend once said "Death is not the enemy."  Indeed it is not.  Suffering is.