an example of how words matter.
Typically, the conversation regarding ‘code status’ starts with the provider saying something along the lines of, “if your heart stops or you stop breathing, do you want us to resuscitate you?”.
I didn’t understand that this question is so wrong on so many levels until my palliative medicine fellowship- and that was in my 25th yr of being a doctor. Again, so much for thinking I was pretty good at this communication stuff.
To start, consider what this question really implies.
In layperson’s terms: ‘when you die (i.e., heart stops, breathing stops = death) do you want us to bring you back (resuscitate you)?’ This is heavy stuff and demands a more intimate conversation than this declarative yes/no question affords. What is needed is an honest discussion that explores a patient’s overall goals; and then the ‘code status’ should codify those goals.
But that will be a future post because the reality is that many providers have this type of ‘code status’ conversation with patients all the time. So, this post is aimed at making this conversation more meaningful and honest.
and it just takes the addition of one little word.
Background info
The majority of the non-medical population knows CPR only from what they get from Hollywood. In the typical scenario, someone collapses from a cardiac arrest, CPR is started, and then the patient magically awakens, looking better than they did before the cardiac arrest. Reality is not that clean or successful.
And another little-known fact to non-medical folks, is that the medical community defines successful resuscitation as ‘ROSC’ i.e., return of spontaneous cardiac function. In plain English- a beating heart. The patient’s cognitive or overall function are not considered as part of the definition of success. It just means the patient’s heart has restarted and is beating on its own. Not everyone would agree with that definition of success.
Plus remember, most of the patients that receive cpr are already sick to some extent, and no matter how quickly cpr is initiated, there will be a period of time where the brain is getting insufficient oxygen. So particularly for a patient in the advanced stages of cancer or heart failure, often the best outcome after cardiac arrest is for the patient to now be much sicker, or more likely, that patient is alive only because they are maintained on life support and therefore will eventually die in the icu. Is that what the patient is hoping for when they say “yes, I want to be resuscitated!” Maybe, but likely, not. You really didn’t really ask them.
And to repeat something I said earlier, providers need to remember what it is you are you really asking the patient. It sounds sterile to talk about the heart stopping, but you are asking someone what they want when they die. So be a little humble.
The typical discussion
If the conversation starts with “if your heart stops, do you want us to resuscitate you?”, just about every patient will answer “of course, do everything!”, because they don’t want to die. Plus, this declarative sentence sounds definite that you can successfully ‘bring them back’ in the manner they saw on tv. (and don’t forget the issues around ‘hope’).
And when they answer “of course”, their crisp response kind of brings the discussion to an abrupt end. But if you think resuscitation is not in your patient’s best interest (because their underlying condition already has such a poor prognosis) you’ll find yourself in the uncomfortable situation of then bringing up what cpr can actually accomplish: possible broken ribs, intubation, being on machines, etc….. Only now, after you asked the question are you painting the realistic picture of what cpr may actually accomplish for ‘this patient’. It can come across as if you are trying to convince the patient to change their mind. But the patient just told you they don’t want to die. To now start backtracking breeds distrust from the patient. And worse, the result is that the patient will get ‘everything’ when that might not be exactly what they wanted, had they truly understood what they were agreeing to.
Now add an additional word.
And that word is: attempt.
Say it aloud and hear the difference.
“Do you want us to resuscitate you?” comes out definite and sharp. “Do you want us to attempt resuscitation?” comes out a bit softer and sounds as if there’s more information coming. In the chart, DNR becomes DNaR, and that extra little letter makes all the difference.
For one, it’s a more honest way to ask the question. Without this word, your phrase sounds like resuscitation is always possible and positive- which it’s not. The addition of attempt adds uncertainty, and often you can see this in the patient’s expression when they answer. So even if the patient answers ‘of course’, you can now have a rejoinder of ‘let me explain what it could look like’ and thereby open up a discussion about the likelihood of success and what that may look like for this patient. You are having a back and forth conversation, rather than trying to talk them out of their decision. It completely changes the dynamic of the conversation.
It is just one additional word, one that may seem insignificant, but actually can promote a more honest and open discussion about a critical decision.
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