They say a broken clock tells the correct time twice a day.   I guess that’s can apply to terrible medical articles in the lay press as well.

During a discussion about a patient with complicated medical issues, my colleague mentioned that she believes that a patient’s code status can impact the way they are treated by providers during their hospital stay.  So, she prefers her patients to remain “full code” unless they are imminently dying.  The implication being that patients will not receive appropriate care because a code status of “DNR” is interpreted by providers as meaning- keep comfortable, but do not treat.  She referred me to a recent column in Investor’s Business Daily (3/28/2018) for support.

This column was a source of great consternation.   The premise was indeed that patients whose code status is DNR have worse outcomes than patients who are full code.  Which if true is devastating and needs emergency attention by our healthcare system, and if false, is a terrible bit of ‘fake news’ to get into the lay press.

The premise is not supported by facts.

Part of me does not want to bring attention to this column, because it was filled with so many errors, and lack of supporting data.

But I have to be honest- even this error laden column (i.e., the broken clock theory) had some valid points.

The opening reads: “Patients, beware.  When you’re admitted to a hospital, you’re routinely encouraged to sign a Do Not Resuscitate order”.  This is totally wrong.  Patients are routinely asked whether they have completed an advance directive (and if so, for a copy) and those without are encouraged to complete one.  But I’ve worked at a number of hospitals, and did an informal survey of my friends across the country, which confirms that patients are not being encouraged to make themselves DNR (and we’ve already talked about it being DNaR not DNR).

And it only gets worse- by the end, the columnist says “most resuscitated patients can expect a relatively good quality of life.  Even elderly resuscitated patients bounce back half the time with no neurological impairment”.  No references are offered to support this totally incorrect statement.   The facts are that unless it’s a resuscitation done by Hollywood with their >75% success rate, in the real-world hospital situation, cpr is ‘successful’ <20% of the time.  Plus, remember from a prior post, success is typically defined as spontaneous return of cardiac function- nothing about cognitive function can be implied from these statistics.

And with respect to the main thrust of the column- that patients with DNR code status have worse outcomes and higher mortality rates than those patients who are ‘full code’ due to their code status, the author is taking this from on research published by an orthopedics group at the Brigham and Woman’s hospital.

However, the authors clearly state:  Concern has been expressed previously that DNR status may carry inadvertent care provider bias, or the so-called “failure to rescue” hypothesis. This could lead to inadequate or insufficient care, extending beyond withholding CPR or intubation and ventilation. Our study was not designed to evaluate this specifically”(emphasis mine).

Which kind of takes a bit of the wind out of the Investors Business Daily premise.  Likely patients with DNR code status, were more frail, and had more co-morbidities, yet underwent the operation to ensure comfort (having a fractured hip- is NOT comfortable).  Importantly, the study demonstrated that post-op morbidity rates were not statistically significantly different between the patients who were full code or DNR.

This column does bring up an important point.  The author mentions that providers don’t uniformly understand what the DNR order means- and it can be interpreted to mean, if the patient gets sick- not to treat.

And truthfully, there are providers that feel that someone with a code status of DNR should never be in an intensive care unit, or should never be intubated, or should never start dialysis.  But they are wrong.

There is nothing inherent to the DNR order itself that means if the person who is still alive, gets sick, that potentially life prolonging treatments should not be started.

The National POLST Paradigm  is a voluntary approach to end-of-life planning that emphasizes eliciting, documenting and honoring the treatment preferences of seriously ill or frail individuals using a portable medical order called a POLST form. If a seriously ill or frail patient wants to use a POLST form, his/her health care professional will complete it after talking with the patient about his/her diagnosis, prognosis, treatment options, and goals of care. In the event of a medical emergency, when time is of the essence for medical decision-making, the POLST form serves as an immediately available and recognizable order set in a standardized format.

The POLST is different from an advance directive- because it has the power of being a medical order- and as such, medics and other medical professionals should follow it.  Because an advance directive is solely a legal document, it does not have the power of being a medical order.

In my state, CA, it’s called a Physician Orders for Life sustaining treatment (POLST).

Because each state has to do everything differently (sarcasm), it has various other names:  MOLST: Medical Orders for Life Sustaining Treatments, POST: Physician Orders for Scope of Treatment, POLST: Provider Orders for Life Sustaining Treatments.  But what they all share is that code status, i.e., whether or not to attempt resuscitation (CPR) applies only to a patient in cardiac/respiratory arrest, i.e., they have no pulse and/or they are not breathing.

Resuscitation status in and of itself has nothing to do with what providers should do when the patient is still alive yet very sick.  That is covered by a separate section of the form.  So by itself, a DNR order should not prevent providers from intubating someone if they are in respiratory distress; doesn’t prevent starting dialysis if in acute renal failure; doesn’t impede the use of iv antibiotics for infection; and is not a contraindication for surgical intervention for a potentially treatable surgical condition.  But sadly, the truth is that sometimes, it can.

I just wish the column did a better job at advancing this conversation than it did.  Instead it was just  inflammatory to get attention.

And it got attention.  Now I’m trying to use it to advance the cause.

You can’t go by code status alone to determine acceptable treatments:

For some patients DNR means:   if I get sick- shift me to comfort care and let me die peacefully.

For other patients DNR means:  do everything (including intubation and ICU care) if I still have a pulse and try to help me get better, but if cardiac/respiratory arrest- let me die in peace.

And for still other patients DNR means:  start treatments, but not aggressive treatments that would require and ICU transfer, and if no improvement or further decline, then shift to comfort focused care so I can die peacefully.

And that’s why the conversation which leads to the code status is so important.  And this must be clearly documented and explained to all providers caring for the patient.

More on this in an upcoming post…..