From the Editor:
Speaking in "Code"
Discussing resuscitation options with the chronically ill
Emergency physicians deal with end-of-life (EOL) issues daily. According to a recent JAMA Network article, we're pretty good at knowing when EOL is near. But few of us are comfortable discussing the subject with patients and their families. "Code," "No Code," "CPR," "resuscitate," etc. are buzz words we use easily, but the lay public doesn't have a clue.
"Allow Natural Death" (AND), a decades-old concept from the nursing literature, may be a better way to engage chronically ill patients being admitted near the EOL The approach works like this: Rather than use "No Code" or "Full Code" or any option in between, try saying something like “You've been very sick for a long time. As usual, we’ll do everything we can to help you. But, what if - while you’re here in the hospital - your heart were to stop beating or your breathing stopped and you died a natural death, [PAUSE for patient's reflection] would you want us to do anything about that?”
This question reframes the whole EOL question and returns control to the patient. The mood in the room lightens and the response is almost always “Of course not! I’ve always hoped I would die a natural death. I don’t want to die hooked up to a bunch of tubes and machines.”
This approach has worked wonders in my own practice and is supported by a palliative care physician and hospice director with whom I have discussed it. The consensus is that the language we currently use to discuss and document code status isn't doing us or our patients any favors. Both specialists point out that it's much easier for them to have these discussions and get a better sense of the patient’s goals and values when another doc has already had a thoughtful conversation on the subject.
Try it. You might like it.
