Code Status Errors Can Be Prevented

  1. Patient education for code status is crucial to proper care. How many times have you come on shift and met a reasonably healthy patient who is a DNR?

    Code Status Errors Can Be Prevented

    The code status of a patient admitted to the hospital is probably one of the most important pieces of information on the patients chart. Yet physicians, residents, and hospitalists spend approximately 2minutes discussing this vital piece of information with their patients. As nurses we have all experienced situations very similar to the one I am about to describe....I am in the middle of obtaining the admission history from a patient who has just been brought in for chest pain with borderline troponins. Most likely he will either have a stress test or heart cath in the morning, pending consultation by the cardiologists. The resident comes into the room and performs a pretty thorough history and physical with the patient. As he is about to leave he asks the patient about his "code status". The patient is naturally a little confused by this question, so the resident clarifies further, "If your heart were to stop would you want us to push on your chest, put a tube down your windpipe to help you breathe, maybe even a tube down your throat to feed you, and give you a lot of medications. Or would you rather we just let you go quietly?" It was of absolutely no surprise to me when the patient answered that he would want to go peacefully. The resident nodded and left the room. A moment later the DNR status appeared on my screen.

    Let's stop here a minute to review some key points:

    The patient is 52 years old and married. He has a full-time job and no other co-morbidities other than mild hypertension and achy knee joints from years of hiking. The patient is probably going to have cardiac testing of some sort in the next 24 to 48 hours. The resident has presented a seemingly biased view by describing what sounds like horrific interventions to the patient without explaining their purpose or potential length of treatment.

    As a nurse I have to wonder if the patient truly understands what he has agreed to, so I begin to ask him some very pointed questions.

    "Do you know what a DNR is?" I ask. "No", replies my patient.

    "If your heart stops right now and you want to be a DNR,that means I will have to stand here and let you die. No CPR and no shocks to restart your heart. Is that what you want?"

    The patient, whose eyes are now as big as saucers says, "No! I want to live!!! I just meant that I did not want to live the rest of my life on a ventilator." I walk out to the nurses' station and inform the resident that the patient is very confused about what the different code statuses mean and would like a clearer explanation before he goes any further. The resident,to his credit, happily went into the room and spent another 10 minutes explaining code status options to the patient. In the end, the patient decided to be a full code and to fill out an advance directive to address any wishes that he might have beyond the initial attempt to save his life. This scenario is quite common, but as we all know the reverse happens as well. A patient who is 89 years old with Stage 4 metastatic lung cancer to the liver and brain on 8L of oxygen comes in for acute on chronic respiratory failure and requests to be a full code. As nurses we all can assume that the patient's doctors have either not had a very important conversation with this individual or the patient is in serious denial about her situation and prognosis. Conversations about code status are vital to our patients, and as such 2 minutes is not enough time to cover the options available or what the outcomes might be. Some hospitals have recognized this issue and have begun to roll out code status patient education initiatives to ensure that patients are as well informed as possible. Videos and questionnaires are two increasingly popular options being trialed. Others have yet to recognize this need in their patient population and are missing an opportunity to ensure patients are making well-informed decisions.

    I would challenge JCAHO to review this need on a nationwide basis and encourage hospitals to incorporate policies to address this issue and prevent patient harm. In the meantime, nurses (especially new nurses) should feel empowered to review a patient's code status with them. Ensuring that patients understand what their status is and requesting the physician to step in and provide more education if needed is a critical component of the nurse's job as a patient advocate.

    How many times have you "caught" a code status issue with a patient?

    What was the outcome?
    What initiatives are happening in your work place to educate patients about code status? [/COLOR][/FONT]
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  3. by   Gods_nurse
    I'm glad that you felt the need to bring this topic up. You are correct in the scenario. I have seen it many, many time thru the 27 years of nursing. However, I resent JACHO!! Putting big government and rules on issues are not the answers to everything. Helping those in the healthcare field with ideas of different ways to present code status, possibly even coming up with a clearer version of various code statuses, etc. would assist in a more positive outcome in my opinion. Possibly have some of the educators suggest some scripts as guidelines for different situations that might present themselves.
  4. by   Here.I.Stand
    My experience has been more of the opposite: people being full code who have no idea that "lifesaving measures" can mean broken ribs, anoxia, a trach and a PEG, months in an LTACH, and then LTC.