Code Status & Advance Directives
Goals of care discussions define what treatments align with patient values. POLST/MOLST translates goals into actionable medical orders. DNR/DNI ≠ comfort care. Full code ≠ always appropriate. Document clearly.
🔍 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 ≠ "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.
🚨 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.
🧪 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
💊 Medications
No specific medications for code status discussions. For symptom management in comfort care transitions:
| Symptom | Medication | Dose |
|---|---|---|
| Pain | Morphine Sulfate | 2–4 mg IV q2h PRN or 5–10 mg PO q4h |
| Dyspnea | Morphine Sulfate | 2 mg IV q2h PRN (opioids treat air hunger) |
| Anxiety | Lorazepam (Ativan) | 0.5–1 mg IV/SL q4h PRN |
| Secretions | Glycopyrrolate (Robinul) | 0.2 mg IV q4h PRN or Scopolamine (Transderm Scōp) patch |
| Nausea | Ondansetron (Zofran) | 4 mg IV q6h PRN |
| Agitation/delirium | Haloperidol (Haldol) | 0.5–2 mg IV q4h PRN |
Comfort care ≠ 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.
📋 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 → adult children → parents → 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
📋 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.
📋 Case 2 - Surrogate Decision-Making for Incapacitated Patient
Patient: 68M with severe ARDS from aspiration pneumonia, intubated day 12, FiO₂ 80%, vasopressors × 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 → 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").
📋 Case 3 - Rapid Decompensation Requiring Emergent Decision
Patient: 82M with ESRD on HD, severe HFrEF (EF 15%), admitted with NSTEMI. Overnight: flash pulmonary edema → BiPAP → 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.
⚡ Summary
Know Exactly What Each Order Limits
DNR: no chest compressions or defibrillation if pulseless. That is all it means. DNI: no endotracheal intubation, but BiPAP and everything else remain available. Comfort measures only: symptom relief with no disease-directed treatment. DNR is not DNI, and neither is comfort care, yet they are treated as a single package on wards every day.
DNR Does Not Mean Do Not Treat
A DNR patient can still receive ICU care, vasopressors, dialysis, antibiotics and surgery. The order addresses cardiac arrest and nothing else. Treatment quietly narrowing after a DNR is a documented and real phenomenon, and it is a failure of care, not an implication of the order.
Never Ask If They Want Everything Done
The question is uninformative, because nobody says no. It also implies the alternative is abandonment. Explain what each intervention actually involves and ask which outcomes would be acceptable, then recommend the plan that fits the answer.
Share Real CPR Numbers
In-hospital CPR survival to discharge is about 15% overall. A witnessed shockable rhythm is 30 to 40%; metastatic cancer, advanced age with comorbidity, or arrest while on vasopressors is around 5% or lower. Patients and families systematically overestimate success, largely from television, so the number itself changes decisions.
Distinguish the Documents
An advance directive is a legal document stating future wishes; a healthcare proxy names a decision-maker; POLST or MOLST is an actionable medical order set signed by a clinician and valid across settings, including for EMS. An advance directive in a drawer does not direct a paramedic; a POLST does. Verify what exists rather than assuming.
Ask What the Patient Would Say
Substituted judgment, not what the family wants. Reframing it as reporting the patient's values rather than choosing for them relieves the guilt that drives requests for non-beneficial treatment. When wishes were never expressed, fall back on best interests and be explicit that that is what you are doing.
Comfort Care Is Active Care
Transitioning to comfort measures means treating symptoms aggressively while stopping disease-directed therapy. Opioids at appropriate doses for dyspnea and pain do not hasten death, and withholding them out of that fear is the commonest way patients are left to suffer. Titrate to symptom relief.
Document and Revisit
Write the conversation, not just the order: who was present, what was discussed, what the patient valued, and the reasoning behind the plan. Code status is not permanent: revisit it as the clinical picture changes, since a decision made on admission may not fit a week later. Involve palliative care early, which improves quality of life and in some populations survival.
📄 One Pager
Text version
PALLIATIVE CARE · One Pager
Code Status & Advance Directives
Goals of care define which treatments match the patient's values; code status is the output, not the starting question. DNR ≠ comfort care, and full code ≠ always appropriate.
Terminology Residents Confuse
- Full code: all resuscitative measures, CPR, intubation, vasopressors, defibrillation.
- DNR: no compressions or defibrillation if pulseless. Nothing else is limited, so ICU care, antibiotics, and surgery all continue.
- DNI: no endotracheal intubation, but BiPAP and medications remain available, so a DNI patient can still be escalated.
- CMO: symptom relief only, no disease-directed treatment, hospice-level care.
- Advance directive: legal document anyone can complete for future care. It must be interpreted and translated into orders, so it is not directly actionable at the bedside.
- POLST/MOLST: physician-signed portable medical order for serious illness, actionable immediately, covering CPR, level of intervention, antibiotics, and artificial nutrition.
CPR Numbers To Quote (best to worst)
- Witnessed shockable VF/VT: ~30–40% survive to discharge, the best-case scenario patients picture from television.
- Overall in-hospital CPR: ~15% survive to discharge; ~25% achieve ROSC, so most who are resuscitated still never leave the hospital.
- Age > 80 with comorbidities: ~5% survive to discharge.
- Metastatic cancer: < 5% survive to discharge.
- On vasopressors at arrest, or sepsis-related arrest: < 2%.
- Give the actual numbers, not adjectives. Patients given quantitative outcome data choose DNR more often than those given qualitative descriptions, because you cannot consent to an outcome you cannot picture.
The Conversation, Step by Step
1
Ask permission: "Would it be okay if we talked about what's most important to you regarding your medical care?" Asking first lets the patient signal readiness, so the rest of the conversation is actually heard.
2
Assess understanding: "What is your understanding of your illness and where things are?" You cannot correct a mental model you have not heard.
3
Explore values: "What's most important to you? What are you hoping for? What are you worried about?" These answers are what your recommendation will be built on.
4
Share prognosis: wish-worry framing, "I wish things were different, but I'm worried that..." It delivers honesty without sounding like you are taking hope away.
5
Recommend: "Based on what you've told me is important, I would recommend..." Families in crisis cannot process an open menu; code status is a medical recommendation, not a choice you outsource.
6
Document: code status, healthcare proxy, POLST, then tell every covering team. A decision no one can find is a decision that will be reversed at 3 am.
Comfort Care Symptom Orders
MorphinePain: 2–4 mg IV q2h PRN or 5–10 mg PO q4h. Dyspnea: 2 mg IV q2h PRN, opioids treat air hunger
Lorazepam (Ativan)0.5–1 mg IV/SL q4h PRN for anxiety
Glycopyrrolate (Robinul)0.2 mg IV q4h PRN for secretions, or scopolamine patch
Haloperidol (Haldol)0.5–2 mg IV q4h PRN for agitation and delirium
Ondansetron (Zofran)4 mg IV q6h PRN for nausea
- Comfort care means treating symptoms aggressively while stopping disease-directed therapy. At appropriately titrated doses, opioids for dyspnea do not hasten death.
Documentation
- Code status in the EMR with the rationale, so the next team understands why, not just what.
- Name the healthcare proxy or POA explicitly, because that person's decision carries legal authority when the patient cannot speak.
- Update the POLST, because it is the order that travels with the patient outside the hospital.
- Write a limited or conditional code verbatim ("DNR except in case of X"), because anything ambiguous defaults back to full code.
- Notify all covering teams, and if a patient states a wish verbally, complete formal paperwork; verbal statements are not actionable in an emergency.
Common Traps
- Asking "Do you want us to do everything?" Nobody says no, so the answer carries no information and cannot support informed consent. Explain what each intervention involves and ask which outcomes are acceptable.
- Treating DNR as "do not treat." DNR addresses cardiac arrest only.
- Doing CPR on a DNR patient because the arrest cause looks reversible. Treat the cause aggressively (calcium for hyperkalemia, treat anaphylaxis), but that is not CPR, and DNR still applies unless a limited code was specifically requested.
- Surgery: do the preoperative "required reconsideration" conversation to define which interventions are acceptable during and after the case, because most intraoperative arrests have reversible causes (anesthesia, bleeding, arrhythmia).
Who To Involve, And When
- Family conflict: identify the legally designated proxy first; if none, follow your state's surrogate hierarchy (spouse → adult children → parents → siblings), because only one voice can be the decision-maker.
- Reframe to substituted judgment: "What would the patient want?" is preferred whenever their values are known; fall back on the best-interest standard only when wishes are completely unknown.
- Prognostic uncertainty or a family that needs time: offer a time-limited trial (e.g., 48–72h) with specific measurable endpoints, because it lets families keep hoping while creating a natural decision point.
- Impasse after repeated meetings: palliative care, then ethics committee consultation.
- Emergency with no valid documentation: honor full code, there is no legal basis to withhold, then hold the formal conversation once stabilized.
Key Evidence
- Ehlenbach, 2009 in-hospital CPR survival falls with age and comorbidity; patients over 80 have ~5% survival to discharge.
- Kaldjian, 2009 quantitative CPR outcome data shifts patients toward DNR more than qualitative description does.
- Wright, 2008 end-of-life discussions lead to less aggressive care, earlier hospice, and better quality of life.
- Temel, 2010 early palliative care in metastatic NSCLC improved quality of life and survival.
- Sykes, 2003 appropriately titrated opioids for symptom control do not hasten death, the basis of the principle of double effect.
- Quill, 2009 time-limited trials as the tool for prognostic uncertainty.
Related Topics
Family Meeting FrameworkGoals of Care & Symptom ManagementHospice Eligibility CriteriaNon-Opioid Symptom ManagementOpioid Rotation ConversionPalliative Extubation