CHEST Guidelines-The-Importance-of-Clarity-for-Hospital-Code-Status (1)

The-Importance-of-Clarity-for-Hospital-Code-Status (1)

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The article, written by J. Randall Curtis and Ferdinando L. Mirarchi, addresses the critical importance of clarity in hospital code status orders, particularly regarding CPR and intubation during medical emergencies. For over 60 years, practices have been in place to guide medical staff during in-hospital cardiac arrests with CPR and advanced cardiac life support. Code status orders, such as do-not-resuscitate (DNR) and do-not-intubate (DNI) instructions, are designed to prevent undesired interventions.<br /><br />Dr. Rubin's retrospective cohort study highlights persistent confusion concerning these orders, as examined in a single-center study. Many hospitals, including the hospital in the study, do not separately distinguish between DNAR and DNI in their electronic systems, leading to potential misinterpretations and risks for patients. The study documents that incorrect documentation and misunderstanding of code statuses, such as treating DNR as a blanket refusal for all intensive interventions, persist among healthcare providers.<br /><br />To address these issues, hospitals must implement clear policies delineating three specific code statuses: DNAR/DNI, DNAR/intubation-ok, and full code. These categories aim to guide providers during emergencies. However, confusion can still arise due to improper interpretations and assumptions about patients' broader care preferences.<br /><br />The article suggests several solutions to improve the situation. These include ensuring discussions about resuscitation and intubation are treated as guidance for emergencies only, verifying patients' values and preferences in non-emergent situations, and improving communication on advance care planning. Engaging patients in discussions about their values and goals before considering specific treatment plans can improve understanding and documentation without oversimplifying complex care decisions. Improved training and communication technology, such as video decision aids, offer additional opportunities to enhance these discussions.<br /><br />Clear and concise code status policies, combined with well-executed communication strategies, can potentially mitigate unnecessary interventions and align patient care with their preferences more effectively.

Keywords

hospital code status

CPR

intubation

DNR

DNI

medical emergencies

advance care planning

communication strategies

patient preferences

healthcare providers