‘Code status’ discussions with seriously ill patients should always take place in the context of the larger goals of care, using a step-wise approach.  This Fast Fact introduces an approach to having these discussions; Fast Fact #24 discusses disagreements about ‘code status.’  Prior to any discussion of a do-not-resuscitate (DNR) order, physicians must know the data defining outcomes and morbidity of cardiopulmonary resuscitation in different patient populations (see Fast Fact #179) and care settings (see Fast Fact #292 regarding DNR orders in the Operating Room). 

1. Establish the setting.   Ensure comfort and privacy; sit down next to the patient. Ask if family members or others should be present. Introduce the subject with a phrase such as: I’d like to talk with you about possible health care decisions in the future.

2. What does the patient understand?  An informed decision about DNR status is only possible if the patient has a clear understanding of their illness and prognosis. Ask an open-ended question to elicit patient understanding about their current health situation.  It is important to get the patient talking – if the doctor is doing all the talking, it is unlikely that the rest of the conversation will go well.  Consider starting with phrases such as: What do you understand about your current health situation?  What have the doctors told you about your condition? If the patient does not know/appreciate their current status this is time to review that information. 

3. What does the patient expect?  Ask the patient to consider the future. Examples of ways to start this discussion are What do you expect in the future? or What goals do you have for the time you have left—what is important to you?  This step allows you to listen while the patient describes a real or imagined future. Many patients with advanced disease use this opening to voice their thoughts about dying—typically mentioning comfort, family, and home, as their goals of care.  If there is a sharp discontinuity between what you expect and what the patient expects, this is the time to clarify. 

Listen carefully to the patient’s responses; most patients have thought a lot about dying, and only need permission to talk about what they have been thinking.  Setting up the conversation in this way permits the physician to respond with clarifying and confirming comments such as:

So what you’re saying is – you want to be as comfortable as possible when the time comes? Or – What you’ve said is – you want us to do everything we can to fight, but when the time comes, you want to die peacefully?  Whenever possible, ask patients to explain the values that underlie their decisions: Can you explain why you feel that way?

4. Discuss a DNR order.  Use language that the patient will understand; give information in small pieces.  Don’t introduce CPR in mechanistic terms (e.g. “starting the heart” or “putting on a breathing machine”). Never say Do you want us to do everything? “Everything” is euphemistic and easily misinterpreted.  Using the word “die” helps to clarify that CPR is a treatment that tries to reverse death.  To most lay-people, when the heart and/or lungs stop, the patient dies. 

If the patient and doctor mutually recognize that death is approaching and the goals of care are comfort, then CPR is not an appropriate medical intervention and a clear recommendation against CPR should be made.  You can say:  We have agreed that the goals of care are to keep you comfortable and get you home.  With this in mind, I do not recommend the use of artificial or heroic means to keep you alive. If you agree with this, I will write an order in the chart that if you die, no attempt to resuscitate you will be made.  

If the clinical situation is more ambiguous in terms of prognosis and goals of care, and you have no clear recommendation, the issue of DNR can be raised by asking:  If you should die in spite of all of our efforts, do you want us to use heroic measures to attempt to bring you back? Or, How do you want things to be when you die?  If you are asked to explain “heroic measures”, then describe the purpose, risks and benefits of CPR in greater detail. The clinical pearl here is to start general and become specific later in the conversation.

5. Respond to emotions.   Strong emotions are common when discussing death.   Typically the emotional response is brief.  The most profound initial response a physician can make may be silence, providing a reassuring touch, and offering facial tissues (see Fast Fact #29).

6. Establish a plan.  Clarify the orders and plans that will accomplish the overall goals you have discussed, not just the DNR order.  A DNR order does not address any aspect of care other than preventing the use of CPR. It is unwise and poor practice to use DNR status as a proxy for other life-sustaining therapies. Consider using words: We will continue maximal medical therapy to meet your goals.  However, if you die, we won’t use CPR to bring you back. Or, It sounds like we should move to a plan that maximizes your comfort.  Therefore, in addition to a DNR order, I’d like to talk further with you how we can best do that.

References

1. Quill TE and Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Int Med. 1996; 125:763-769.
2. Buckman R. How to break bad news: a guide for health care professionals. Baltimore, MD: Johns Hopkins University Press; 1992.
3. Junkerman  C, Schiedermayer D.  Practical Ethics for Students, Interns and Residents. 2nd Edition. Hagerstown, MD: University Publishing Group; 1998.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published July 2005; 3rd Edition May 2015. Current version re-copy-edited May 2015.