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By the Meriter Hospital Ethics Committee
In an era of increasing personal responsibility over one's healthcare decisions, Meriter Hospital feels it is important to provide basic information about "Codes." This article should help you better understand what a Code is, what happens during and after a Code, and your rights as a patient when it comes to Codes. We do not intend it to provide you with legal advice of any kind.
Occasionally at Meriter Hospital, a patient or visitor will have breathing or cardiac problems that threaten their lives. In these cases, we announce "Code Blue" over the public address system, summoning emergency help to respond to the situation.
The following questions are answered in this article:
- What Does Resuscitation or Code Mean?
- What Goes On During a Code?
- How Successful are Codes?
- What Happens After a Successful Code?
- Do All Patients Have This Done?
- What if a Patient Does Not Want This Done?
- What Does No Code Mean?
- Is It Possible to Have Some Part of a Code but Not All of It?
- What Are a Limited Code's Advantages and Disadvantages?
- How Do Staff Members Know They Should Not Call a Code?
- Can Patients Change Their Minds about being a No Code?
- Does an Advance Medical Directive Affect Code Status?
- How do I decide about being a No Code?
- What happens after I leave the hospital if I am No Code?
What Does Resuscitation or Code Mean?
When hospital patients or visitors have a life-threatening problem with their breathing or heart, emergency help is summoned. Specially trained people immediately respond and try to revive (resuscitate) the patient. Meriter Hospital calls a Code Blue whenever this situation arises.
What Goes On During a Code?
If the person is not breathing, we will start artificial respiration. Someone responding to the Code will blow air into the patient's mouth; soon after, a tube is put down the windpipe. This tube is later connected to a breathing machine (ventilator or respirator.) If the patient's heart has stopped or is not working adequately, compressions will be done on the chest. These two things ñ artificial respiration and chest compressions ñ are frequently called CPR (CardioPulmonary Resuscitation). Depending on the person's specific problem, we may apply an electrical shock to the chest to correct a heart rhythm disturbance. We also frequently inject medication into the veins.
How Successful are Codes?
Chances of survival vary according to the underlying medical condition and the person's overall health and age. Recent studies have shown that only about 15% of patients (1 in 7) who have CPR done survive initially. Of these patients, about 2/3 have sustained brain damage, and do not return to their previous level of functioning. Most of these require nursing home care for the rest of their lives. Patients with metastatic cancer have NO chance of surviving CPR.
What Happens After a Successful Code?
Treatment after a Code varies. We transfer most people to a critical care area after a Code. Many people will need a respirator (breathing machine) ñ some for only a few hours, some for a long time. Patients frequently require continuous infusions of medications to help their heart and blood pressure. Some patients recover after receiving these treatments, others remain permanently unconscious or in a coma.
Do All Patients Have This Done?
NO, many patients decide they want death to occur naturally, and do not want to try to delay it by having CPR done. Some patients make this decision based on their religious or philosophical beliefs, others because they prefer a natural death, and understand the great chance of being dependent on others for their daily care should they survive CPR.
What if a Patient Does Not Want This Done?
It is important that patients discuss their preferences regarding CPR with their physicians. Together, they can decide the best plan. They also should discuss these wishes with family or anyone else selected to make healthcare decisions for another person through, for example, the Power of Attorney for Healthcare. When you are admitted to the hospital your physician should ask you what your preferences are regarding CPR. If this topic is not raised, or if you are so sick that you cannot have this discussion, then we will assume you want CPR done unless you have made your preferences known through your Advance Medical directives, or in prior conversation with family members, health care agents or your primary physician.
What Does No Code Mean?
If a patient with No Code status needs resuscitation, we will not summon the emergency team. Instead, the patient will continue to receive the usual and any additional comfort measures needed. The No Code designation does not affect other aspects of patient care. In other words, No Code does not mean No Treatment. Routine medications, tests and treatments will be done as indicated and agreed to by the patient and physician.
Another term for "No Code" is "Do Not Resuscitate" or DNR. At Meriter we also use "Do not Intubate" or DNI. Intubation is when the breathing tube is inserted and connected to a breathing machine. These two terms are most often used together, as in "DNR/DNI".
Is It Possible to Have Some Part of a Code but Not All of It?
In some situations it makes sense to treat certain conditions with some, but not all, emergency measures. We call this a Limited Code. For example, a patient who is prone to heart rhythm problems may want emergency medications and electrical shocks used, but not chest compressions or artificial ventilation.
What Are a Limited Code's Advantages and Disadvantages?
A Limited Code allows the patient to choose specific treatments that have some chance of being helpful, while not choosing those that might be painful, futile or just unwanted. On the other hand, a Limited Code can result in the patient surviving, but in a worse state of health. For example, a patient may have a normal heartbeat restored, but have brain damage from lack of oxygen.
How Do Staff Members Know They Should Not Call a Code?
Information about Code status is placed in the chart. However, since this information may not always be readily available, the hospital recommends that patients who opt for No Code status wear a purple wristband. Wearing the wristband clearly communicates the patient's wishes to staff anywhere in the hospital, and helps prevent treatment that the patient does not want. A patient may refuse to wear the wristband and still maintain a No Code status.
Can Patients Change Their Minds about being a No Code?
Patients always have a right to change their Code status. Because of this possibility, we routinely ask patients about their wishes each time they are admitted to the hospital.
Patients may tell their physician or nurse that they have changed their minds at any time during their hospitalization. Changing Code status for the duration of a surgical procedure might be appropriate for surgical patients; they should discuss this possibility with their surgeon and anesthesiologist.
Does an Advance Medical Directive Affect Code Status?
An Advance Medical Directive, called a Living Will or Power of Attorney for Health Care, can be helpful in guiding care if the patient is no longer able to decide. An Advance Medical Directive may or may not include specific information about the person's wishes about being resuscitated.
In either case, it is important that the person named to decide (the healthcare agent) understands the patient's wishes. Even if the written document includes the patient's wishes to not be resuscitated, the physician must discuss this with the patient and write an order in the chart. This order clarifies and communicates the patient's wishes to all healthcare staff involved.
How do I decide about being a No Code?
This is a decision that is usually best made in discussion with your physician. The factors involved in making the best decision for you may include your spiritual or religious beliefs, the kinds of medical illnesses you have and the chances of medical cure, and how close to death your physician thinks you may be.
What happens after I leave the hospital if I am No Code?
If your decision to be No Code is permanent, we can arrange for a special bracelet at home that indicates "Do Not Resuscitate", and has your doctor's signature on it. If EMS (911) is ever called to your home if you have a medical emergency, the paramedics by law must attempt resuscitation unless you are wearing one of these bracelets. If you ever change your mind about your preferences, you merely cut off or otherwise remove your bracelet.
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11/21/2006
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