Background      Discussions about resuscitation orders are often complex and emotional. Additionally, there are different contexts of code status discussions such as routine discussions with patients upon hospital admission who are at low-risk of in-hospital arrest vs discussions with patients with advanced illnesses who are highly unlikely to survive an in-hospital arrest. Discussing code status can be challenging during an initial encounter with a patient because clinicians often do not have enough time or information to fully understand the underlying medical situation nor the patient’s values.  It is our experience that many clinicians struggle to find accurate, concise, and compassionate language when leading these discussions on an initial encounter and skip it entirely or ask euphemistic questions which fail to educate the patient on the very basics of what is at stake (e.g., asking Do you want us to do everything?). This Fast Fact, and Fast Fact #365, suggest language for clinicians when having these conversations.  These are not meant to be verbatim scripts, but rather examples that clinicians can use for teaching or personal adaption. Additional Fast Facts that address code status discussions include #23, #24, #179, and #292.  

Routine code status discussions upon hospital admission     It is common practice and institutional policy that adult patients are asked about code status upon admission to the hospital, regardless of their underlying condition and prognosis (1). These discussions can be frightening for the patient (e.g. the patient worries that the clinician is introducing the topic because the patient’s prognosis is worse than they have been led to believe). The following tips are meant for patients with good or uncertain prognoses, for whom you think a ‘full code’ order is reasonable and medically appropriate. Any prior out-of-hospital orders for life-sustaining treatments or healthcare directives should be reviewed prior to this discussion. Typically, it is best to have this discussion towards the end of the admission process, after discussing the plan and expectations for a patient’s hospital admission. 

• Normalize & contextualize the discussion: I have one more topic to discuss with you. It is something I discuss with every patient I am admitting to the hospital, regardless of how healthy or sick they are. Some of my patients have strong opinions about this, and it is important I know what they are so I can make sure that I respect their wishes.  
• Provide basic definitions: It’s about something we call your ‘code status’ or ‘resuscitation orders.’ This means directions to your medical team about what we should or shouldn’t do if you were to unexpectedly become very ill and your heart stopped beating while you were here. 
• Hand the conversation to them. What have you heard about the term ‘code status’ or ‘resuscitation orders’? Patients often respond helpfully to this question and you quickly get a sense if they know what you are talking about or not.  If they have clear wishes about their own code status, they often readily provide them. It can also help you identify their emotional readiness to continue the conversation. Emotions are an expected part of this conversation, and it is critical to explore any strong reaction to understand the emotions or values that underlie it. 
• Empathize, normalize, partner, and reassure. I know this can be upsetting to discuss. Or—No one wants to think about this possibility. Or–I want you to know I don’t think it’s likely we’ll be facing this.
• For patients who have adequate context for the discussion and voice a code status choice, thank them for the discussion and educate them as to how your institution designates code status.
• Educate patients who need more context. A simple, explicit explanation, avoiding euphemisms, is adequate for most patients. Present cardiopulmonary resuscitation as a package of interventions, and not a menu of options. What I am talking about is what we do if a patient becomes critically ill in the hospital and we are worried they might die. If a patient’s heart is not pumping blood, we sometimes attempt to restore life using cardiopulmonary resuscitation or CPR. This means pushing on a patient’s chest with our hands to try to pump blood through the body, using electricity to shock a patient’s heart into beating properly again, and placing a tube down a patient’s airway and attaching them to a ventilator machine which breathes for them. Doing this does not always lead to survival or recovery, and some of my patients would rather we not attempt it, which is why I ask everyone about it. 
• Wait for their response. As appropriate, provide additional information about what CPR & critical illness entail, in-hospital CPR outcomes (see Fast Fact #179), or what care for a patient who has a DNR order looks like if they become critically ill. Many patients will be surprised to learn of the poor survival outcomes of in-hospital arrests and want to discuss this further. You might say Overall the changes of someone surviving CPR is about 1 in 7. Some people are willing to go through all the medical treatments and being on a ventilator machine for that chance. Others say – If the chances are that low, I would not be willing to do that. Can you tell me about the kind of person you are?

• There are situations in which intubation may need to be considered for patients who have not suffered an arrest such as in the case of progressive respiratory failure.  Patient outcomes for invasive mechanical ventilation alone are much better than those for in-hospital cardiac arrest. This should be discussed and clarified when appropriate.  
• Let the patient know the discussion may be revisited as you get a better understanding of their medical situation. I will update your chart to reflect our discussion. As we understand more about your medical situation, I may ask to talk with you about your code status again. 

References

1. Patient Self Determination Act. H.R. 4449, 101st Cong. (enacted 1990).
2. Dumot J, Burval D, Sprung J. Outcome of Adult Cardiopulmonary Resuscitations at a Tertiary Referral Center Including Results of “Limited” Resuscitations. Arch Int Med. 2001; 161(14):1751-8.
3. Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients.  Cambridge University Press. New York, NY. 2009.
4. White J, Fromme E.  “In the Beginning…”: Tools for talking about resuscitation and goals of care early in the admission.  Am J Hosp Pall Care.  2012: 30(7): 676-82.

Conflicts of Interest: None

Version History:  Originally edited by Sean Marks MD; first electronically published in November 2018.Authors’ Affiliation:   University of Minnesota Medical School, Minneapolis, MN.