EP 165: Ethics of a Full Code, DNR, Partial Code

Ethics of a Full Code, DNR, Partial Code

Full codes and partial codes cannot be avoided whenever there is an emergency. But the question is, should people have an option to be a partial code? Is there any benefit to partial codes? Many people think there should only be two options; full code or no code.

What is the code status?

Code status is used in all hospital settings. All patients admitted to a hospital or outpatient center are assigned a code status. A code status essentially means the type of emergent treatment a person would or would not want to receive if their heart or breathing were to stop. 

Your chosen code status describes the type of resuscitation procedures you would like the health care team to do if your heart stopped beating and/or you stopped breathing. During this medical emergency, resuscitation procedures are provided quickly to keep you alive. This emergency procedure is commonly known as cardiopulmonary resuscitation or CPR. 

In the same way, there are different treatment options and goals. The expected outcomes after cardiac or respiratory arrest differ depending on the person, the severity of illness, the cause of arrest, and other factors. It is essential to discuss code status before a crisis occurs and as a condition changes.

Outcome of Resuscitation

Cardiac arrest is when the heart stops beating. About 350,000 cases occur each year outside of a hospital, and the survival rate is less than 12 percent. CPR can double or triple the chances of survival.

Even though CPR can restart someone’s heart, it can also cause harm or even prolong the dying process. The success of resuscitative efforts is not like how it is on tv, that stats are low. In 2016, the survival rate for adults after a cardiac arrest was:

  • Out-of-Hospital Arrest: 12%
  • In-Hospital Arrest: Less than 25%
    • The average survival-to-discharge rate for adults who suffer in-hospital arrest is 17% to 20%.
  • Survival rates are lower for patients with advanced age, cancer, sepsis, renal failure, or liver failure. The survival rates for patients with a chronic illness or advanced illness average 5% and less than 1% respectively.
  • More than 40% of survivors are discharged with a significant decrease in their functional ability. 

Different Types of Code Statuses

Just like there are different treatment modalities there are different code statuses. There isn’t only 1 route and you can choose different options, however, there is a limit on what we can and can’t do. 

    1. Full Code: We do anything and everything to try and bring you back. This includes CPR, intubation, medications, lines, and procedures. 
    2. DNR: This is a Do Not Resuscitate order. When your heart stops we will not attempt to do anything. We will let you pass without any interventions. 
    3. Partial Code: This one can be a little complicated because there a few measures you can choose to have done or choose not to have done. 
      1. Meds Only: In this situation, if your heart were to stop we would not perform CPR or intubation. What we would do is use medication to bring you back. We can push epinephrine, give bicarbonate, start levophed or other pressors to try and keep your heart beating or start it back up. 
      2. No CPR: Some patients do not want CPR performed but are open to everything else. Defibrillation, intubation, and medication are all used. 
  • DNI – Do not intubate. There are patients that want everything to be done but not get a breathing tube placed

What is the Ethics of Partial Codes?

The main objection to partial code orders is that they are ineffective in sustaining life and can potentially deceive the patient and/or patient’s family into believing that resuscitation is possible when, in fact, the patient’s death is imminent. 

  • The concept is that you need hands on the chest to resuscitate someone. Once a heart stops beating there is no more circulation so there is no oxygen being fed into the tissue. Every second cell dies without any pressure from the heartbeat. 

People always want to make exceptions for everything. But when it comes to life it’s either you’re 2 feet in or 2 feet out. Is there such a thing as partial living? Then why should there be partial codes? Why should we hold back or delay treatment if the person/family is set on them surviving? Why not give them a full opportunity?

Many people would agree that there should only be 2 options; 

  1. Full code as in to do everything
  2. No code as in does nothing but comfort. 

It’s either we try to keep them alive or not. Why do people persistently make partial codes as in they want to “maybe” live? 

Why partial codes?

Many people don’t understand the reasoning behind a partial code. Let’s think about it. 

If you have ever seen a code blue with good chest compressions it is not a pleasant thing to witness. A lot of times a guy pushes on someone’s chest very hard and most of those times it leads to the sternum and other bones being broken. 

We can understand how enduring it is for the family to see. They see their loved ones and want them to at least have some chance. But partial codes give the lowest chance. 

  • Maybe there should be orders that state can intubate for respiratory distress but now when a pulse is lost. But then what if the pt loses a pulse during intubation. 

How much time do we have until brain damage?

  • When cardiac arrest occurs, cardiopulmonary resuscitation (CPR) must be started within two minutes. After three minutes, global cerebral ischemia, the lack of blood flow to the entire brain, can lead to brain injury that gets progressively worse.
  • By nine minutes, severe and permanent brain damage is likely. After 10 minutes, the chances of survival are low.
  • Even if a person is resuscitated, eight out of every 10 will be in a coma and sustain some level of brain damage. Simply put, the longer the brain is deprived of oxygen, the worse the damage will be.

TIME STAMPS:

00:00 intro
00:51 Plugs
01:23 Episode Introduction
02:37 What happens in a code status

05:25 A very slim chance of surviving a cardiac arrest
07:25 What is a code status?
09:16 Full Code, No Code, Partial Code
11:58 Family members are not educated well with code status
14:45  Partial Code rarely or does not work at all
17:45 Sad situation of a full code patient
20:12 How much time do we have until brain damage?
21:53 Call for physicians to step up and decide code status in real-time
25:12 Improvements that can be done
27:25 Patient’s family are very reliant on healthcare providers
30:27 Getting clear on what code to choose

 

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