Code status: Full Code.
This is a false assumption that many will make about young, healthy patients.
I certainly made this inference on many occasions throughout my medical training, often stating: “Your code status is full code, right?” rather than the open-ended: “What is your code status?”
I was Full Code, myself, and didn’t have the insight as to why someone would choose not to be, not to fight for the privilege of life.
This was until two transformative experiences during my residency.
The first involved a patient with no written power of attorney and the three children who consistently argued over the plan of care until the patient passed away.
They lashed out at every team member, with myself as the least experienced of the team, experiencing the worst of it.
I still remember the ICU attending advising that no healthcare professional should ever overlook verbal abuse, and that I had the right to report it.
But I never did.
Although, I had mixed emotions about this, ultimately I realized it was a grieving family, grasping at straws because there was no plan.
The second experience was my last shift on my ICU rotation:
3 of the patients I was taking care of with my team died, each during their own code blue, the last of which was the most traumatizing of all.
The last was most impactful because it involved a large family that had decided on full code and after the 3rd code blue on this same patient, they agreed it was enough.
I still remember breaking down into tears, being sent to the call room to finish my notes and go home. And then not having the energy or the emotional capacity to attend a funeral the following day (meaning a few hours after I got home from this shift).
This was the experience I remember most vividly from my training and THE one that prompted me to officially and legally change my code status to DNR/DNI at the age 28. There was no doubt in my mind that I would ever make a hard situation harder for my family or settle for anything less than an excellent quality of life.
I only momentarily doubted this decision.
This happened when I got married and my husband and I were completing our Advance Directives and he was confused and surprised by this choice.
I informed him that quality of life means everything to me, that I would want him to move on and be happy rather than taking care of a “vegetable,” and that I was not afraid of death because it is inevitable and not in my control.
I questioned this decision a second time when I found out I was having my first child, and then really started to have reservations when I considered my daughter growing up without a mother and my husband having to raise a child on his own.
I realized that I had a choice after Full Code: That if I were Full Code, and received CPR or was intubated, and then subsequently minimally disabled, I would want to be there for my daughter and teach her how to rise from adversity and treat everyone with respect.
If not, I had the ability to state my exact wishes in my Advance Directive.
It made me realize that code status is beyond black and white, that there is a grey zone and it is that grey zone where the confusion lies and why I think it is essential for medical trainees to learn how to communicate about advance directives, and why there needs to be continued education for Attending Physicians.
No matter what your specialty, this experience was a part of your training.
As a Family Physician, although it does become less jarring as I frequently participate in this dialogue, it is never easy. There is a human being and their family on the other side, and there is hardly enough time.
So, how do we better prepare for this?
Is there something else we can do early on in our medical training to approach this with compassion, non-judgement and patience in the limited time we are given?
According to a study from June 2022, republished in the American Journal of Hospice and Palliative Medicine in April 2023, forty seven medical students were enrolled in an ACP curriculum over three years. Although a small N size, the findings were statistically significant: comfortability with the discussion improved from 4% to 36%; the student’s need for attending supervision declined from 51% to 0%; and all students either agreed or strongly agreed that they felt more prepared to have this discussion with a real patient. The most beneficial was group discussions and simulated patients.
In another study from March 2019, republished in the American Journal of Hospice and Palliative Medicine in July 2019, a different approach was taken.
As is still common practice, real standardized patients were utilized, but they were an older demographic.
Two-hundred and twenty three medical students participated in these interactions after lectures and supplemental information and there was a statistically significant improvement in seven studied domains:
(1) introduce subject of EoL;
(2) define advance directives;
(3) assess values, goals, and priorities;
(4) discuss prior experience with death;
(5) assess expectations about treatment and hospitalization;
(6) explain cardiopulmonary resuscitation and outcomes; and
(7) deal with own feelings about EoL and providers’ limitations
Although both studies focused on third and fourth year medical students, I would offer that if medical education continues its traditional path (first two years didactic and last two years clinic), it may be beneficial to begin this training in the second year to make the transition to clinical practice and communication with patients smoother.
With AI technology on the rise, such simulations are likely to become easier to widely implement.