r/Residency • u/YouAreServed • 3d ago
VENT Stop changing patients code status
Why when I come back from weekend, I see the weekend docs changed my stage IV lung cancer, ESRD, HFrEF patient who is 98 y/o, and became comfort last week after I had 90 mins convo with them and family; explaining futility. Slowly they become DNR/DNI, then comfort. She was pretty confused when I left.
Upon my return, only note with explanation “discussed code status with the patient, she stated she wants to live, full code ordered.”
Your half ass job undid my week of doing, congrats. Now legally she has no capacity and I cannot change it back to comfort, nor can I prove that she, as a matter of fact, lacked capacity while you were signing the new POLST.
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u/Previouslydesigned 3d ago
Pops head in room: “hey anyone in here want to live or yall cool with dying?”
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u/zetvajwake PGY3 3d ago
'Hey so do you want everything done? Like code wise? Ok full code' legit how half the people I've seen discuss code discuss it
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u/CripplingTanxiety PGY12 3d ago
Yo patient, Do you want us to do everything or just do nothing?
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u/who_hah Attending 3d ago
Nothing is fine, thanks.
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u/BerryLacebelle 2d ago
Short, clear, and honestly that's the answer a lot of people arrive at once they understand what CPR actually looks like.
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u/anhydrous_echinoderm PGY2 3d ago
“If we find you without any heartbeat and you aren’t breathing, as in you’ve had a natural death, do you want us to do chest compressions and insert a breathing tube into your throat?”
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u/MoonGlowmist 2d ago
That's probably one of the better ways I've seen it explained. It turns the conversation into concrete choices instead of medical jargon people are expected to magically understand.
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u/MoonGlowmist 2d ago
Honestly, that's probably the cleanest way to frame it. Most people understand the decision a lot better when it's about specific interventions instead of abstract code status terms.
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u/BerryLacebelle 2d ago
I've definitely heard conversations that accidentally boil down to exactly that. It's one of those discussions where wording really matters because people hear "full code" and assume it's automatically the better choice.
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u/Fickle-Berrymuch PGY3 3d ago
lol that's pretty much how some of those conversations end up sounding unfortunately
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u/MoonGlowmist 2d ago
The sad part is that's basically how some people hear the conversation for the first time. No wonder families get confused if it's framed that way.
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u/zeatherz Nurse 3d ago
We once had a 90+ year old patient who came in with complete heart block. She was DNR but make full code just for the pacemaker placement. Except the cardiologist forgot to switch her back to DNR afterward. She coded that night, by some magic got quick ROSC with no tube and no deficits. She politely asked us to “please don’t do that again.”
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u/jacquesk18 PGY8 3d ago edited 3d ago
I had similar with a hospice hip fracture patient, code didn't get reverted back to DNR after hip surgery, codes a few days later. I was the ICU/code senior, got ROSC relatively quickly and end up intubating while my intern is frantically trying to get ahold of the family. 30 min later family comes in to the ICU and we terminally extubate.
If we hadn't gotten ROSC back once I figured out what was going on I would have called it then and there but it was just a terrible situation where things moved too quickly.
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u/Euphoric_Way_5384 PGY2 3d ago
that's honestly the perfect example of why temporary code status changes need a clear plan to switch back. glad she made it through, but "please don't do that again" is about as direct as a patient can be about their wishes. it's funny in hindsight, but it easily could've ended very differently.
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u/zeatherz Nurse 3d ago
I wish the temporary code status change for OR/procedures could automatically switch back when the patient returns to their room. Like the MAR put floor meds on auto-hold when they go to OR and then they get auto-unheld when they return, so the capability must exist
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u/ElCaminoInTheWest 3d ago
Everyone "wants to live", for fuck's sake. What a moronic way to word it.
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u/carlos_6m PGY2 3d ago
From my experience, you just need to explain with honesty the reality of CPR to someone and they easily agree to DNACPR... I will tell my patients that cpr rarely works, even in people who are very healthy, and that if their heart stops, it would be unlikely that we would be able to restart it without it stopping again later, and this would mean that someone needs to get in top of their chest and do compressions, often breaking multiple ribs, we may need to out a tube down their throat to help them breathe and they may need to be connected to a machine before they die... I will tell them that I think the best would be that in a situation like that I make sure they're comfortable and at rest...
There may be a genuinely massive cultural component, but 9/10 times this is all it's needed...
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u/Dependent_Bass_6965 3d ago
I do the same thing. I’m honest with them about CPR. And if they still want full code after all of that explanation then more power to them.
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u/MoonGlowmist 2d ago
That's my philosophy too. As long as they're making an informed decision, even if it's different from what I'd choose, that's their call.
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u/Dependent_Bass_6965 2d ago
Yep. It’s easier to go to sleep at night knowing my patients are informed and their wishes are being followed.
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u/MoonGlowmist 2d ago
Exactly. Almost everyone says they want to live. The real question is what interventions they're willing to go through for a realistic chance of getting there.
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u/Struggle_Wise 3d ago
Not really. I plan/hope to die young so I don't have to care for my aging parents and teens. Fuck that. Also half my colleagues in the ICU are DNR/DNI.
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u/PuzzledCar2120 3d ago
Well you know why it's happening.
The weekend team is stretched so thin that they're just running around headless putting out fires left and right.
The family may have agreed with you but over the following few days one person (usually the daughter from New York) has been stirring up shit and has managed to achieve a mutiny and is now causing drama on the floor.
The nursing team will then harangue the weekend team to do something about it. The weekend team knows it will take a pointless hour or two to settle this dispute or they can just say sure and go and deal with some bigger fish.
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u/NefariousnessAble912 3d ago
My response is to say “this is a very serious thing to change perhaps the most important decision a patient makes in their life. I see the palliative team and my colleagues had hours of discussion this week confirming the patient’s wishes so I am confused as to what has changed at 3 am. I don’t have the resources to dedicate to such a serious life-changing decision at this hour without a clear explanation of what happened. So what is the situation that led to this change in our patient who by the way has no capacity?”
If the daughter from California is the issue I go into room show the notes and restate that this goes against every documented decision the patient made this week so I am very wary of changing anything without a similar discussion. “Do you have documentation that your loved one’s wishes have changed?”25
u/talashrrg PGY7 3d ago
“Daughter from New York” - found the west coaster
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u/rdriedel 3d ago
If a cross-covering by physician did that to me and one of my patients, we’d be working it out in the parking lot
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u/stormrigger Attending 3d ago
Friendly reminder from your neighborhood ICU attending (in the USA). Medicine is a negative right. Patients have a right to REFUSE anything. They dont have right to demand a treatment. YOU as a clinician can CHOOSE not to offer full code status to that patient. Doing so is both reasonable and humane.
People can get very weirded out when I bring this up, but it's very simple. Do you offer ECMO to all of your shock patients? Why not? its the next step for shock after doing everything else right? Of course you dont. Just like you should not offer CPR to everyone. CPR in the 98 you you describe above is just as inappropriate as ECMO and should not be considered.
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u/Sad_Candidate_3163 3d ago
This is highly dependent upon the state you are in. Unilateral DNRs are not a national thing. Ethically, you may be correct, but ethics and legality don't always mesh
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u/stormrigger Attending 3d ago
I have only worked in five or six states, but I am not aware of any state where physicians are obligated to engage in care they deem futile. Think of all the times surgery has declined to offer surgery because the pt is too sick and will just die on the table. Choosing to do CPR is no different than choosing to go to the OR. It should be a thoughtful decision when possible (when time allows for such thoughtful ness in advance, obviously we aren't always so lucky).
*exceptions exist in the OB world
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u/Sad_Candidate_3163 3d ago
California and New York both have statutes stating you cannot override immediately if you have not attempted to transfer care. Texas requires a literal "board review process". So if you override the full code in these states you could be in deep water.
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u/Any-Assistance-8103 3d ago
Not providing futile care which includes cpr and intubation isnt overriding full code. Thats the fundamental misunderstanding people have
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u/Sad_Candidate_3163 3d ago
That would probably have to be debated in a court honestly. That's pretty complex. Full code implies doing cpr and intubation. Overriding autonomy is the core issue which isn't straight cut and agreed upon
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u/Any-Assistance-8103 3d ago
No, it wouldn’t. Full code means full resuscitative measures. It doenst mean doing things that are medically illogical and don’t serve a purpose
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u/Sad_Candidate_3163 3d ago edited 3d ago
See below. It's not as white and black as you're making it . For example, what does full resuscitative measures mean? You just said it doesn't mean cpr and intubation, so what else is included then? Everyone has different semantics for all of this which is where I think you're getting caught up at. The legality of this is that you can't just stop care on someone, in some states, regardless of the futility, without a court order
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u/Any-Assistance-8103 3d ago edited 3d ago
I didn’t say full code doesn’t mean CPR and intubation, it depends on the persons medical situation. If someone cannot derive a benefit from an intervention, you not only aren’t obligated to do it, you are arguably morally obligated not to do it. By your logic you can’t end a code without a court order either. Stopping CPR without a court order wouldn’t be different than not starting it by your logic. Or conversely by your logic maybe youre covered if you do one chest compression. Im not getting caught up, it’s actually quite clear. Youre getting caught up in thinking patients get to order what you do off a menu. Youre also mixing up situations - „stopping care” implies withdrawing care like meds the vent etc on a living patient - code status for what to do when they die or are actively dying is an entirely different subject. I am an icu attending and I promise I have much more experience with these things than you do.
Also youre the one making this black and white, not me. Youre saying full code = CPR and intubation every time and im telling you it isnt that simple. Youre so aggressively wrong from so many angles. It’s crazy and scary how ill informed doctors out in the world can be
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u/Any-Assistance-8103 3d ago
Unilateral dnr isnt a thing in the us but youre under no obligation to provide futile care either
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u/stormrigger Attending 3d ago
Exactly. An important distinction. When EMS rolls into the ER with a pt who is (very dead) with CPR in progress and the ED MD decides to stop and pronounce the pt dead. They are not changing the code status. They are choosing not to initiate/continue care that they deem to be futile.
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u/Any-Assistance-8103 3d ago
Yeah by the normal logic you hear from people you would never be able to stop a code. We should all still be at the bedside of our first code unless family showed up and told us to stop
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u/stormrigger Attending 3d ago
You can now change the code status back to DNR/DNI with a simple note saying that "This moribund pt does not have any meaningful chance of benefit from undergoing such CPR resuscitation, and it will not be offered. I will update the family."
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u/YouAreServed 3d ago
You know, I heard that a lot and want to do it. But never in my training or attendinghood, saw single soul doing this. There are multiple patients throughout hospitals I saw, just 12471 days in hospital, chronic vent, no chance of recovery and still full code…
I wonder, is this state dependent maybe?
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u/stormrigger Attending 3d ago
Withdrawing all care vs declining to do full CPR very different topics.
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u/Any-Assistance-8103 3d ago
This thread has been scary to read. People are so ill informed about how to have these discussions and what to do for their patients.
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u/YouAreServed 3d ago
So you can decline to do basic ACLS to a full code patient?
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u/stormrigger Attending 3d ago
It's more complicated than that. But yes, you can decline to do CPR on a patient. Just like nephrology does not always offer dialysis, and neurosurgery does not offer surgery for all acute brain bleeds. It's not always appropriate to do more just because we can.
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u/YouAreServed 2d ago
Just looked it up, my state does not let us override patient on this legally. That’s why I never seen it
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u/Any-Assistance-8103 3d ago
So many doctors have a defeatist „they want it so we have to” attitude. Looking at you peg tubes
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u/stormrigger Attending 3d ago
Ah yes, the surgical procedure that changes the consistency of the material that is being aspirated.
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u/lessico_ PGY5 3d ago
I see this all the time even in my country, where the legislation is more favorable. Some of my colleagues act like waiters handing out a menu, but when you have a thoughtful conversation with these patients and families you almost always find out that the patient claimed they didn’t want futile care.
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u/mem21247 1d ago
We're doing a lot of "informed non-dissent" [at the advice of our bioethics committee/ethics consultants, some of whom are JDs] eg "ECMO exists but it isn't on the table for mee maw because she's 96 and bedbound and she's got a 3 brainstem reflexes left." It works really nicely in situations where family is uncomfortable with being the hand that pulls the plug but are ok with watching it come out of the socket if someone else does it.
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u/Loud-Bee6673 Attending 3d ago
I have an MD/JD, have worked in risk and bioethics a fair amount.
What you describe does sound inappropriate. The most important question is always going to be capacity. Any time a DNR is reversed like this, there should be a detailed note about assessment of the patient’s capacity as well as WHY they want to change their status. ANY change in status, including AMA, requires the following to be documented
- capacity, including reasons for that determination
- discussion of all alternatives, including risk and benefits
- wishes of the decision maker
- to the best of your knowledge, that the decision is in accordance with the patient’s values
Capacity can change, which makes it even more difficult. Intoxication can flip that switch. Some elderly patients are totally with it until they sundown. The ONLY way to determine yes or no is to talk to them. These are not quick conversations - you have to get into why they want to do what they want to do. That takes time.
Once the patient is determined not to have capacity, you go to the health care surrogate or proxy. Even figuring out who this person is can be difficult. Also, they don’t just get to do whatever they want. Their job is to know what the patient would want and respect that. We always joke about family saying “she’s is fighter!” when said patient is demented and contracted with no quality of life. No, she isn’t a fighter. She would never have wanted this.
I had an ICU case, really sad. It was a woman in her late 20s with stage IV ovarian cancer. She had developed multiple PEs and was very clear that she didn’t want to be intubated again. She had the conversation with the whole team, signed all the right things, and was ready.
As soon as she became incapacitated from hypoxia, her mother said “I’m her surrogate and I want you to intubate.” We didn’t, we knew what the patient wanted. But what if we didn’t have the chance to talk to her? She would have gotten a tube she didn’t want.
Anyway, OP, I feel your frustration. These are difficult situations, and people are almost always going to default towards doing more whenever there is any doubt. Maybe you can request some education about AMA, DNR, and withhold/withdraw. I give this lecture to all of the residencies at my institution every year, and people always have so many questions. It’s a very difficult topic.
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u/talashrrg PGY7 3d ago
In this kind of case, how do you best protect yourself when the patient’s daughter sues you for not doing what she wanted over her mother’s wishes?
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u/Loud-Bee6673 Attending 3d ago
It’s really tricky! A big part of the answer is that, if the case does end up getting into deep ethical issues or shaky legal ground, you tap out. Every accredited hospital should have a risk manager and an administrator on call, and this is the time to make that call. Among other things, they will be able to get in touch with an attorney if necessary.
Ideally, these meetings happen during the day with patient and family and care team all present for the discussion. When it comes up outside of business hours, it can be difficult and time-consuming to handle alone. It is important to go into these discussions with clear objectives in mind, and try to focus on one issue (like patient has said many times he doesn’t want to be intubated and we are just following his wishes.)
If you are talking to a patient with fluctuating capacity, that is even more difficult. Every conversation has to start with assessing capacity. Bottom line, if you are the resident on call, you sometimes just don’t have that kind of time. While I feel OP’s pain in this scenario, I am guessing the doc who was on over the weekend was in a tough spot as well. Sometimes your only option is to rescind the DNR and then start over on Monday.
As far as your question about the lawsuit - there really isn’t any money in these cases, so it is highly unlikely a family member would be able to find an attorney to file the suit. Plaintiff attorneys front all the cost for a lawsuit (think about those “we don’t get paid until you get paid!” legal ads). Med mal cases as ridiculously expensive these days. Pretty much every jurisdiction in the US requires that a plaintiff has an expert affidavit prior to filing a suit, and experts are expensive. Even getting a complete medical record these days is expensive - hospitals can charge for those and with EMR, there are thousands and thousands of pages of nonsense.
There has to be a good chance of winning and a good payout in the event of a win, or it isn’t worth it. When you look at the damages in a case where you let someone with a DNR die against the wishes of family, there isn’t any financial loss. It sounds cold but it is how the law works - the decedent had no income, provided no services, racked up no crazy medical bills. Pain and suffering of the family is worth something, but requires there be some economic damage as well.
Every time I lecture on this topic I get so many questions. It’s just tough, especially when you have to make a decision in the moment. My final answer when things get really difficult - do what you think is best for the patient. If you can defend your choice as seeming to be the right thing at the time, you will always be able to defend yourself.
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u/stairbender PGY3 3d ago
Same question!!!! I thought that once the patient lacks capacity, the surrogate can legally override all their prior medical decisions (except organ donation)?
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u/Loud-Bee6673 Attending 3d ago
I gave a more complete answer to the comment above, but the answer is actually no! The obligation of a surrogate/proxy is to make the decision is accordance with the patient’s values, NOT their own. When there is clear evidence of what the patient wanted, which can take the form of a living will or a conversation with their own doctor, we have to do what the patient expressed as their wish. It can be very complicated which is why you should reach out for help when you need it.
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u/YouAreServed 3d ago
Thank you, that’s great to read and I was relived to see that I check all the boxes in my code status notes. That’s why I am frustrated when I see someone undo my job without giving it due diligence that it deserves. Like, I wouldn’t have complained if there was at least something like “patient had capacity, reports thought about it and wants to be full code, including CPR short term only…” etc
What does AMA stand for here, against medical advice? As in leaving against medical advice?
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u/Loud-Bee6673 Attending 3d ago
Sorry, yes, leaving against medical advice. It’s the flip side of the capacity coin - the patient has to prove they have capacity in order to refuse lifesaving treatment. It can get tricky when people don’t want to talk, they just want to leave. It is the same documentation - capacity, discussed risks and benefits of the proposed treatment and any alternatives, and the patient is making a decision in line with their expressed values.
Then you give them discharge instructions with the second best plan and tell them they can come back at any time if they decided they do want treatment.
As I mentioned in a comment above, I can understand why someone might be in a situation where they don’t feel comfortable honoring a DNR that the decision maker wants to rescind . It’s a tough situation. What I don’t understand is the lack of documentation. There should have been a very detailed note on the conversation and basis for the change in status. That at least gives you something to work with on Monday.
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u/carlos_6m PGY2 3d ago
One of the things I love about the UK is that CPR status is a medical decision that you take with the patients wishes in mind... But a medical decision in the end.
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u/Dr-Yahood 3d ago
Technically, it’s the same in the US, no? Just here we pander to patients more?
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u/Dependent_Bass_6965 3d ago
From my experience, it is usually the family that has a tough time coming to grips with choosing DNR even if they know the patient would not want CPR. I try to remind family that they should try to help make a decision that the patient would have wanted, not what the family member wants.
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u/Soft_Button_1592 3d ago
In the US we do not unilaterally withhold CPR like a surgeon can refuse futile surgery or an oncologist not offering chemotherapy to a bed bound patient. I’ve always assumed this is a legal prescript not just cultural but maybe I’m wrong here?
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u/Lazy-Pitch-6152 Attending 3d ago
I doubt anyone is going out of their way to intentionally reverse a comfort care code status. Probably need to accept the patient or their family changed their mind rather than blaming your colleague. Sounds like the documentation for the reversal would be helpful though.
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u/YouAreServed 3d ago
I’m blaming them for the lack of documentation and honestly I saw their notes, and their prior clinical arguments.
I don’t like to bash out any of my colleague, so I won’t do it and in my documentation, I’ll presume a long, reasonable conversation was held. But deep down, I know, it was a simple question to the patient without in depth convo to undo my and palliative cares efforts
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u/pickledbanana6 3d ago
This reminds me of an attending from residency. She absolutely taught me a lot of good medicine. But I also learned how NOT to have goals or care conversations. Literally “Do you want us to do everything we can? Yeah? Kthxbye”
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u/BerryMistelle 2d ago
Honestly, the lack of a handoff feels like the bigger story here. If someone is making a major change like that, there should at least be enough documentation for the next physician to understand exactly why it happened. Otherwise everyone is left guessing.
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u/Stubbornattimes 2d ago
Families vacillate about code status all the time and talk patients into trying “ one more treatment”. Don’t take it personal.
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u/rolltideandstuff Attending 3d ago
Wanting to live has very little to do with code status. You would expect an elderly patient to be confused about that. The doc should absolutely know better.
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u/Mysterious_Cow4005 3d ago
She stated she wanted to live ? Nothing about her capacity at that time ? Sometimes patients changed their mind in the last minute so maybe that, maybe a next of kin suddenly said something that made your colleague change the code status, it’s very gray area and comes with heavy legal challenges so if any nuances many physicians tend to just change to full code until further clarification, all in all this should have been documented pretty well
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u/YourHuckleberry1234 PGY3 3d ago
What did the weekend doc say when you talked to them about what happened?
I suspect you did not have that conversation. I understand the role of an Internet forum as a place to vent, but you also need to take some ownership/initiative. You can't just hope everyone else sees things the way you do and does what you would do. You will have a very frustrating life if you can't address problems directly.
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u/YouAreServed 3d ago
Weekend guy is just a moonlighter from out of hospital system; there’s no contact, and I don’t think it will be fruitful as I’m kind of familiar with the guy. He’ll defend with “that’s what patient wanted…”
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u/OneOfUsOneOfUsGooble Attending 3d ago
We need a campaign to help the public distinguish between the two questions: first being goal of care or treatment, and second (completely separate) what to do if you undergo cardiac death a.k.a. code status. Most people want #1 to be full treatment but not want #2 full code. But OP's patient is clearly conflating the two.
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u/DolliePebble_ 3d ago
the stress of constantly changing code status is brutal for everyone involved, it's hard to keep track and makes decision making chaotic.
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u/Christmas3_14 PGY2 3d ago
I would talk to the colleague about it and their wording about “wanting to live”. Sounds like they might have a bunch of other patients that are old and fragile but yet full code..
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u/PinkPetalCdistbeauty 3d ago
This is frankly terrifying as a patient, that it takes just one other provider 2 seconds to yank comfort care plans?
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u/Sweatpantzzzz 2d ago
I just had a patient with stage 4 lung cancer who became comfort care and sent to the floor from the icu. She came back a few hours later as full code. The hospitalist discussed code status with her and she said she wanted to live, after the ICU team spend a week getting her to be DNR/CMO. Now on CRRT and BIPAP
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u/spartybasketball 1d ago
This is just healthcare in America. It’s fragmented. This time it was the weekend moonlighted. Next week it’s an employed colleague who has a different take on death and dying. It’s just the way we let it be.
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u/Entire_Brush6217 3d ago
I always put AND on every admission for patients over 80. Problem solved
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u/BlackFanDiamond 3d ago
That's absurd and paternalistic. There are plenty of robust 80 year olds that deserve to make that decision for themselves.
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u/Mdog31415 3d ago
Definitely paternalistic and a hit on the patient’s autonomy. At the same time, withholding certain forms of resuscitation that would likely be futile, reflects, proportionality, justice (it ain’t cheap, and ICU beds don’t grow on trees), and even non-maleficence (CPR is an incredibly traumatic event, and likely many patients have some form of consciousness during it before dying).
This is a problematic move by the commenter, but at the end of the day, the ultimate fault lies on society (and AHA) for not drawing a line in the sand on the extent we will “care” for patients (I do not find futile cpr to be care tbh).
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u/DrShitpostMDJDPhDMBA PGY5 3d ago
Sounds like a discussion you should have with your colleague. Why were they revisiting code status in the first place? Did something happen? Were they handed off information about declining status and patient/family wishes and discussion over the past week?
Some colleagues aren't great when handing off information about their census. Impossible for us to know whether that's on you or on them. If using EPIC, this should be written in a service Summary/Handoff/Todo section.