'No Code' Does Not Mean No Care

Taking care of hospitalized patients has become much more challenging due to the increased intensity and complexity of their illnesses. Because a great deal of care can be safely provided in other locations, it's often only the sickest people - those requiring the most intense levels of care - who end up in the hospital. As a consequence, it is the obligation of the entire health care team to anticipate problems and define the best plan of care. This is especially true for people who are critically ill or are in the final stages of a chronic disease such as heart failure or emphysema. A question that you or your family member will likely be asked under these circumstances is whether or not an attempt at resuscitation is desired in the event of a life-threatening medical emergency or a "code."

"Code" Calls for Lifesaving Actions
A "code" occurs when an individual's breathing stops or is inadequate to maintain consciousness and/or one's heart stops beating or beats ineffectively. When these or similar circumstances take place, cardiopulmonary resuscitation (CPR) is started. This is an aggressive effort involving pressing rhythmically and forcefully on the chest in an effort to move blood through the heart while air is forced into the lungs either through mouth-to-mouth breathing or via the insertion of a tube into the trachea (windpipe).

A variety of intravenous fluids and chemicals are usually also being administered to support blood pressure and to treat abnormal heart rhythms. As health care providers, we know that attempts at resuscitation involve efforts that, although unintended, can be quite brutal and may even cause some degree of injury. We would prefer not to do this if the underlying illness is so severe that the likelihood of providing any lasting benefit is virtually non-existent.

Some people may think doctors are looking for a reason to limit care or to deny patients life-saving treatment or even to save money, but thoughtful decisions during codes are an important element of compassionate care. They are also an indication that the health care team is trying to avoid causing any unnecessary suffering by using a medical treatment that likely will not work.

To put this in context and in comparison to what sometimes is depicted in the media, a study on the long-term effectiveness of CPR showed that of hospitalized patients successfully revived as a consequence of CPR, about one in ten left the hospital alive and that over half of those people died within in the next 22 months.

Documents Can Make Your Wishes Known
Discussions about death and treatments at the end of life are not something most people look forward to. Yet it is far better to have answers to these questions before they are asked in the context of a critical illness. There are two documents that are available from most doctors' offices that help to bring this decision to light that can be completed and brought to the hospital. They are the Living Will and the Power of Attorney for Health Care.

The Living Will is a document in which one makes decisions regarding the kinds of care they would desire in the event of a critical illness if they were not of sound mind at the time. This includes decisions pertaining due to use of a ventilator to sustain breathing, the placement of a tube for feeding and fluid purposes, and whether to withhold antibiotics or other forms of medical treatments.

The Power of Attorney for Healthcare is a document that transfers all medical decision making to another person, often a spouse, child, other relative or good friend. In order for this to be useful, a meaningful conversation must occur where all of the above issues are addressed such that the person who has power of attorney can confidently decide if and when the situation arises.

The Wisconsin Department of Health and Family Services (DHFS) is required by state statutes to make available three advance directive forms. The three forms are:

• Declaration to Physicians (Wisconsin Living Will)
• Power of Attorney for Health Care
• Power of Attorney for Finance and Property

You can obtain copies of the forms either by printing them from the DHFS website or by sending a stamped, self-addressed business-sized envelope to:

Living Will/Power of Attorney
Division of Public Health
PO Box 309
Madison, WI 53701-0309

Having said all of this, I would make the point that choosing to limit interventions in the face of a possible terminal illness is not the same as withdrawing care. Care can still be (and often is) provided through the use of antibiotics and other life-restoring treatments. Patients can be cared for in the intensive care unit regardless of their code status if there is a high likelihood that they will benefit from that care.

Even in situations where the imminent death of a patient has been acknowledged, care continues in the form of pain management and the creation of a supportive environment for the patient and family.

For more information on this topic, see the HealthLink articles CPR Not Always the Answer and Advance Planning is Crucial in Health Care Emergencies.