Goals of care discussions define what treatments align with patient values. POLST/MOLST translates goals into actionable medical orders. DNR/DNI โ comfort care. Full code โ always appropriate. Document clearly.
๐ Overview
Key Terminology
Term
Definition
Full Code
All resuscitative measures including CPR, intubation, vasopressors, defibrillation
DNR (Do Not Resuscitate)
No chest compressions or defibrillation if pulseless. Does NOT limit other treatments.
DNI (Do Not Intubate)
No endotracheal intubation. May still receive BiPAP, medications, other interventions.
DNR/DNI
No CPR AND no intubation. All other treatments still available unless specified.
Comfort Measures Only (CMO)
Focus entirely on symptom relief. No disease-directed treatments. Hospice-level care.
POLST/MOLST
Portable medical order translating goals into specific treatment decisions (antibiotics, fluids, hospitalization, CPR)
Advance Directive
Legal document expressing wishes for future care when unable to decide (living will, healthcare proxy)
Key Evidence: In-hospital CPR survival to discharge is ~15% overall, but < 5% in metastatic cancer and < 2% with sepsis-related arrest Ehlenbach, 2009. Early palliative care consultation improves quality of life and may extend survival Temel, 2010. Most patients prefer comfort-focused care when given accurate prognostic information Wright, 2008.
DNR โ "do not treat." A patient can be DNR and still receive ICU-level care, antibiotics, surgery, and full medical management. DNR ONLY addresses cardiac arrest.
๐จ Management
Framework for Goals of Care Conversation
Step
What to Say
1. Ask permission
"Would it be okay if we talked about what's most important to you regarding your medical care?"
2. Assess understanding
"What is your understanding of your illness and where things are?"
3. Explore values
"What's most important to you? What are you hoping for? What are you worried about?"
4. Share prognosis
"I wish things were different, but I'm worried that..." (wish-worry framework)
5. Make recommendation
"Based on what you've told me is important, I would recommend..."
6. Document
Document code status, healthcare proxy, POLST. Communicate to all team members.
CPR outcomes to share with patients: Overall in-hospital CPR survival to discharge ~15%. Witnessed shockable rhythm (VF/VT): ~30-40%. Metastatic cancer: < 5%. Age > 80 with comorbidities: ~5%. On vasopressors at time of arrest: < 2%. Sharing specific data helps patients make informed decisions Kaldjian, 2009.
Never ask: "Do you want us to do everything?" This question is uninformative - nobody would say no. Instead, explain what interventions entail and ask what outcomes are acceptable.
๐งช Workup
Information to Gather
Current understanding of illness/prognosis
Prior advance directives or POLST forms
Healthcare proxy/POA identification
Religious/spiritual considerations
Family dynamics and decision-makers
Prior experiences with hospitalization, ICU, mechanical ventilation
What quality of life means to the patient
๐ Medications
No specific medications for code status discussions. For symptom management in comfort care transitions:
Symptom
Medication
Dose
Pain
Morphine Sulfate
2โ4 mg IV q2h PRN or 5โ10 mg PO q4h
Dyspnea
Morphine Sulfate
2 mg IV q2h PRN (opioids treat air hunger)
Anxiety
Lorazepam (Ativan)
0.5โ1 mg IV/SL q4h PRN
Secretions
Glycopyrrolate (Robinul)
0.2 mg IV q4h PRN or Scopolamine (Transderm Scลp) patch
Nausea
Ondansetron (Zofran)
4 mg IV q6h PRN
Agitation/delirium
Haloperidol (Haldol)
0.5โ2 mg IV q4h PRN
Comfort care โ no care. Transitioning to comfort measures means aggressively treating symptoms while stopping disease-directed therapy. Opioids for dyspnea do NOT hasten death at appropriate doses Sykes, 2003. This is the principle of double effect: the intent is to relieve suffering, and the risk of hastening death is an accepted but unintended side effect.
๐ On Rounds
Pimp Questions
What is the difference between an advance directive and a POLST?
Advance directive is a LEGAL document completed by anyone (regardless of health status) expressing wishes for future care. It designates a healthcare proxy and/or describes treatment preferences. It is interpreted and must be translated into medical orders. POLST (Physician Orders for Life-Sustaining Treatment) is a MEDICAL ORDER signed by a physician for patients with serious illness.
Can you perform CPR on a patient who is DNR if they have a reversible cause of arrest?
No, unless the patient or surrogate specifically requests a "conditional" or "limited" code status. DNR means no CPR regardless of the cause. However, you CAN and SHOULD treat the reversible condition aggressively (e.g., give calcium for hyperkalemia, treat anaphylaxis) -treating the cause is NOT CPR. If a patient or family specifically requests "DNR except in case of X," this should be clearly documented.
How do you handle disagreement between family members about code status?
(1) Identify the legally designated healthcare proxy/POA - their decision has legal authority. (2) If no proxy, follow your state's surrogate hierarchy (spouse โ adult children โ parents โ siblings). (3) Focus on "what would the patient want?" (substituted judgment). (4) Ethics committee consultation if unable to resolve. (5) Document all conversations and decisions.
What is the survival rate for in-hospital CPR?
Overall ~25% achieve ROSC, ~10-15% survive to discharge. In metastatic cancer, survival to discharge < 5%. In witnessed VF/VT arrest, ~30-40% survive. Ehlenbach, 2009 showed elderly patients (>80) have ~5% survival to discharge after in-hospital CPR. Giving patients specific numbers helps informed decision-making.
What is a time-limited trial and when should you use it?
A defined period (e.g., 48-72h) of aggressive treatment with specific, measurable goals. If goals not met, the family and team reassess. Useful when prognosis is uncertain or family needs time. Set clear endpoints: "If off vasopressors by Friday..." Quill, 2009 proposed this as a key palliative care tool.
What is the legal hierarchy of surrogate decision-makers?
Varies by state but typically: (1) Court-appointed guardian, (2) Healthcare proxy/POA, (3) Spouse, (4) Adult children, (5) Parents, (6) Siblings. Some states recognize domestic partners. The proxy's decision should reflect substituted judgment (what the patient would want), not the proxy's own preferences.
What is the difference between 'substituted judgment' and 'best interest' standard?
Substituted judgment: "What would the patient want based on their known values?" Used when patient's preferences are known or can be inferred. Best interest: "What would a reasonable person want?" Used when patient's wishes are completely unknown. Substituted judgment is preferred when possible.
Should DNR be suspended during surgery?
Yes, this is standard practice per ASA guidelines. A blanket DNR during surgery is inappropriate because most intraoperative arrests have reversible causes (anesthesia, bleeding, arrhythmia). A "required reconsideration" conversation should occur preoperatively to define which interventions are acceptable during/after surgery.
What are the components of a POLST form?
Section A: CPR (attempt/do not attempt). Section B: Medical interventions (full treatment, selective treatment, comfort-focused). Section C: Antibiotics (full, limited, comfort only). Section D: Artificially administered nutrition (long-term, defined trial, no artificial nutrition). Must be signed by physician + patient/surrogate.
Clinical Examples
๐ Case 1 - New Admission Code Status Discussion
Patient: 74F with metastatic NSCLC admitted for pneumonia. No advance directive on file. Alert, oriented, ECOG 3. Family present.
Key findings: Progressive cancer despite 2nd-line therapy. Declining functional status over 3 months. No prior documented goals of care conversation.
Management:
Initiate GOC conversation: "Given everything going on, I want to make sure we have a plan that matches your values"
Explore understanding: "What has your oncologist told you about where things stand?"
Clarify values: "If your heart were to stop, CPR has < 5% survival to discharge in metastatic cancer"
Recommend: "Based on what you've told me, I'd recommend focusing on treatments that keep you comfortable"
Document: DNR/DNI with clear rationale, update POLST, notify covering teams
Teaching point: Frame code status as a medical recommendation, not a menu choice. "Do you want us to do everything?" is a harmful question - patients cannot give informed consent without understanding outcomes.
๐ Case 2 - Surrogate Decision-Making for Incapacitated Patient
Patient: 68M with severe ARDS from aspiration pneumonia, intubated day 12, FiOโ 80%, vasopressors ร 2. PMH: advanced cirrhosis (MELD 34). No advance directive. Wife and adult son disagree.
Key findings: Predicted mortality > 90% (MELD 34 + ARDS + vasopressors). Wife wants to continue. Son says "Dad would never want this."
Management:
Identify legal surrogate (wife as spouse has legal priority in most states)
Family meeting with entire care team - present medical reality clearly
Use substituted judgment: "What would he say if he could see himself right now?"
Allow time - offer a time-limited trial: "Let's reassess in 48 hours"
If impasse persists โ palliative care and ethics committee consultation
Teaching point: Time-limited trials are powerful tools. They give families permission to hope while creating a natural decision point. Set specific, measurable goals (e.g., "off vasopressors by Friday").
๐ Case 3 - Rapid Decompensation Requiring Emergent Decision
Patient: 82M with ESRD on HD, severe HFrEF (EF 15%), admitted with NSTEMI. Overnight: flash pulmonary edema โ BiPAP โ worsening. Full code. No family reachable.
Key findings: Impending respiratory arrest. Full code by default. Prior admission note documents patient saying "I don't want to be on machines" but no formal paperwork.
Management:
Honor full code status - intubate if needed (no legal basis to withhold without valid documentation)
Attempt emergent family contact via social work
Document the prior stated wishes in the chart but note they are not legally binding
Once stabilized: formal GOC conversation and advance directive completion
Consider palliative care consult for longitudinal goals discussion
Teaching point: Verbal statements without documentation are not actionable in emergencies. Always complete formal paperwork (POLST/MOLST, advance directive) when patients express end-of-life preferences.
โก Summary
DNR โ Do Not Treat
DNR only addresses cardiac arrest. All other care continues unless specifically limited.
Never Ask
"Do you want everything?" Instead: explain interventions, ask what outcomes are acceptable.
Code status in EMR. Healthcare proxy identified. Communicate to ALL team members.
Related Topics
Family Meeting FrameworkGoals of Care & Symptom ManagementHospice Eligibility CriteriaNon-Opioid Symptom ManagementOpioid Rotation ConversionPalliative Extubation