Palliative medicine consultation is often ordered when there are ‘code status’ issues.  Usually this means the medical team feels the patient ‘should be DNR’ but the patient/family wants ‘everything done’.  There are a number of issues to unpack in these lines (among them that palliative teams are not the DNR team, or that DNaR- do not attempt resuscitation is how it should be worded) but in this post I’ll concentrate on ‘code status’.   Placing ‘code status’ at the center of the conversation about end of life issues is the incorrect frame for the discussion.  What needs to be discussed is what are the overall goals for this patient, and once that is determined, the code status codifies those goals.

Mr RM, 56 years old, presented to the hospital with unremitting back pain. After testing, the diagnosis was widely metastatic neuroendocrine lung cancer. Because he was so frail, chemotherapy was not initially an option.  However, the inpatient oncology consult service hoped that adequate pain control (via radiation therapy and opioid medications) would in turn lead to improvement, keeping open the option that chemotherapy could be possible in the future. Mr RM was discharged home from the hospital and given a follow-up appointment with medical oncology for re-evaluation.

Through a combination of palliative radiation and opioid medications, Mr RM’s pain was controlled. Unfortunately, prior to his oncology appointment, he was again admitted to the hospital, now with delirium secondary to hypercalcemia. Treatment was effective, but due to his continued frail state he was discharged to a skilled nursing facility (snf). During his two-week stay at the snf, he did not improve (he remained bedbound with poor oral intake).  When he was seen at his outpatient medical oncology appointment, he was again found to be delirious from hypercalcemia (calcium 19).

On hospital admission, Mr RM did not have decisional capacity so the admitting provider spoke to his medical power of attorney (MPOA), Mr. RM’s 32-year-old daughter.  Their discussion centered on ‘code status’. Her decision was to continue all possible life-prolonging treatments, including transfer to the intensive care unit (ICU) if indicated; in the event of hemodynamic compromise or cardiac arrest, attempt at resuscitation (CPR) would be acceptable.

Mr RM was admitted to the hospital ICU and aggressive treatment of hypercalcemia was instituted. The next morning, the team placed a request for palliative medicine consultation with the reason for consultation given as: “Hx neuroendocrine cancer, patient not good candidate; should be DNR.”

When I went to see Mr RM, his serum calcium had improved only slightly. He was still delirious—he thought his daughter was his mother, and he was unclear as to where he was. Although lethargic, he aroused easily and denied any active symptoms; he did seem comfortable.

I spoke with his daughter in a private area. She was still coming to terms with her father’s illness. All of this had taken place over a short period of time, just a few months. She was her father’s main source of support, and she had a young family of her own; she was dealing with a lot.

It turned out that she had a good understanding of the extent of her father’s illness with a realistic appraisal of the gravity of his condition. She recognized her father’s frailty, accepted that there were no curative options for his cancer, and understood that chemotherapy to try to control the disease was impossible. She knew her father would likely die soon, and stressed that their primary goal was to optimize his comfort, not necessarily to maximize his length of life.

When we discussed Mr RM’s illness and the natural disease progression, I explained that, left untreated, hypercalcemia often leads to a comfortable death, with little suffering. She was quite surprised by this information. Her relatively brief discussion with the admitting physician about ‘code status’ had led her to believe that hypercalcemia would cause death by ‘heart attack’, a death she feared would be very painful as she equated this with searing chest pain. This was the reason she had wanted to continue all treatments.

We talked about the likely scenario for her father’s death—a gradual decrease in level of consciousness and finally cardiac arrest, and I assured her that any symptoms he might develop could be ameliorated. She was noticeably relieved. With this new understanding and with no reservations, she agreed to a transition to a comfort-oriented approach to care. I spoke to the treating team, and aggressive intravenous fluids administration and other hypercalcemia treatments were stopped, opioids and other comfort measures were instituted, and Mr RM’s code status was changed to DNaR. He died quietly just a few days later, with his family by his side.

While I was glad to have helped Mr RM and his family, I was also left wondering, was a palliative medicine consult really required in order to have this conversation?.  And why did it take so long to have a discussion regarding overall treatment goals in the first place? Why weren’t these issues addressed earlier, like at the time of his initial diagnosis?

• Is the problem-oriented approach to treating patients interfering with seeing our whole patient?, i.e., it’s relatively easy to treat the problem of hypercalcemia, but the underlying cancer and his frailty is another story.
• Is there just not enough time?
• Are these conversations deemed too depressing for the patient or the provider?
• Are providers reluctant to bring up these issues because they are uncomfortable discussing end-of-life issues with patients and their families?
• Do providers worry that it’s not their place to bring up these issues? Do they feel they lack the skills necessary for these conversations?

Probably all of the above is true, to some degree.

My goal with this blog is to help change this dynamic.