Educating Nurses on Therapeutic Discussion of Code Status

Educating Nurses on Therapeutic Discussion of Code Status By: Alanna Wathen

Purpose • Patients are dying in the hospital with no code status, meaning that their end-of-life wants were never discussed. • Physicians scope of practice is to initiate code status discussion and to write any order for end of life care, but often nurses are the ones there when patients have questions. Because of this nurses should be educated on the best ways to therapeutically communicate with patients on end-oflife wants.

Theoretical Framework • Hildegard Peplau’s Theory of Interpersonal Relationships • This theory focuses on the Person, Environment, Health, and Nurse (Gonzalo). • • Who is this person? How do they communicate? Do they have family? What is going on in the environment? Is this patient healthy enough to understand what you are saying? Do you as the nurse have any biases?

Evidence- Code Status Deficit • El-Jawahri et al. (2017) studied 728 advanced cancer patients at Massachusetts General Hospital (MGH). He found that 53% of these advanced cancer patients had a code status of “presumed full code” which at MGH meant that there was no discussion with the patient, so they were automatically labeled this. While in the hospital patients most changed their code status after clarifying their wishes with a doctor and the next highest reason for changing was after being educated on effects of cardiopulmonary resuscitation. • A study was done at Vanderbilt University Medical Center in 2015 which studied the effects of a new tool they were using in their electronic health record. They found that 30% of adults that died in a one-year time frame did not have a code status, and 70% of children. They also found that 93% of Hispanic patients that were admitted never received a code status (Binder, 2015).

Evidence- Best Ways to Communicate • Make sure if the patient has family that they are present, and to do the discussion when the patient is healthy enough to help the family make the decision. • Many researchers agreed that the patient should know what happens when a full code is performed and how successful CPR is. • Downar and Hawryluck worked with 12 physicians that specialized in palliative and critical care. They produced guidelines for end-of-life discussion such as focusing on the patient's goals and values, giving the patient a prognosis and recommendation, and all their end-of-life options (Downar, 2010).

Recommendations for Practice • Make sure when asking patients if they have an advanced directive and what their code status is to educate them on their chosen code status. Use clarifying questions to make sure that is what they want. • Make sure you as the nurse know what the difference between Full Code, DNR, and DNI. • If a patient is DNI, CPR and cardiac drug administration can be performed. • Normalize the conversation with healthy adults by saying that you discuss this with every patient. • Use hope/prepare statements. Such as, “ We will use our top care to give you the best outcome possible, but some people progress faster, and you should prepare yourself for the unexpected. ”

Key Points to Use • Never use the phrases “do nothing”, “do everything”, or “nothing can be done”. • Ask the patient what they already know about code statuses. • Acknowledge a specific goal for the patient's long-term care and focus your discussion off that. • Make sure the patient understands that DNR does not mean do not treat. Have the conversation even though it’s hard! As nurses we must be advocates and that means knowing what the patients wishes are!

References • Binder, A. F. , Huang, G. C. , & Buss, M. K. (2015). Uninformed consent: Do medicine residents lack the proper framework for code status discussions? Journal of Hospital Medicine, 11(2), 111116. doi: 10. 1002/jhm. 2497 Curtis, J. R. , Kross, E. K. , & Stapleton, R. D. (2020). The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19). Jama. doi: 10. 1001/jama. 2020. 4894 • Downar, J. , & Hawryluck, L. (2010). What should we say when discussing ‘‘code status’’ and life support with a patient? A delphi analysis. Journals of Palliative Medicine, 13(2), 185 -195. DOI: 10. 1089=jpm. 2009. 0269 • El‐Jawahri, A. , Lau‐Min, K. , Nipp, R. D. , Greer, J. A. , Traeger, L. N. , Moran, S. M. , . . . Temel, J. S. (2017). Processes of code status transitions in hospitalized patients with advanced cancer. American Cancer Society Journals, 123(24), 4895 -4902. doi: 10. 1002/cncr. 30969 • Gonzalo, A. , BSN, RN. (2019, August 24). Hildegard Peplau: Interpersonal relations theory guide. Retrieved October 01, 2020, from https: //nurseslabs. com/hildegard-peplaus-interpersonal-relationstheory/