By Nicholas Perkins
I recently met a palliative care patient with chronic obstructive pulmonary disorder whose code status was not on file. He described his condition as “breathing through a wet towel.” I listened intently while he shared how it feels to lose his breath when he eats and walks to the restroom. As a competitive runner, I reflected upon the sadness this patient felt as he shared the limiting effects of his illness.
I immediately informed a palliative care nurse about our conversation, and the patient transitioned to hospice care after meeting with the nurse. The POST (Physician Orders Scope of Treatment) form that we completed ensured that the DNR code status he chose in the hospital would remain in effect after discharge, even in a nursing home or an inpatient hospice facility.
In my follow-up visit, I asked if his family knew about his priorities and wishes. We discussed support systems and what would make his transition to hospice care easier. He talked about his legacy and memories. I recognized how he made eye contact with me and acknowledged his relaxed demeanor. I still see the patient reaching for my hand and hear him asking me to pray.
Addressing code status upon admission benefits patients and families. A proactive approach improves patient outcomes, clarifies patient treatment preferences, and creates opportunities for discussing health care advocacy. This upbeat strategy before a code blue is called is critical for elderly patients with frequent hospitalizations and chronic health issues.
The three kinds of code status in an acute care setting are not-on-file, full code, and do not resuscitate (DNR). A not-on-file code status compares to a full code. Various aggressive interventions are performed in code blue situations to restart a patient’s heart. No aggressive actions are performed in that situation for a patient with a DNR status. The patient has died, and staff will respect their wishes for a natural death. Patients who choose DNR wear a particular-colored bracelet to alert staff.
The palliative care physician I work with normalizes code status conversations, mitigating some anxiety and fear. She says, “I have one more topic to discuss with you. It is something I discuss with every patient I visit.” This approach tells patients that addressing code status is standard practice. The mindset, “It’s not what you say but how you say it,” is crucial when addressing code status.
Every hospital chaplain can play a vital role in conversations that address code status. For instance, I recently advocated for a family member by asking if she wanted to discuss code status in the patient’s room or outside it. This family member was the documented healthcare power of attorney and preferred to talk outside the room to avoid frightening the elderly patient.
In those situations, it’s important to practice spiritual listening, which seeks to receive and wonder about what the person shares, rather than immediately respond to it. I recall listening to an angry patient after having a code status conversation. Faith was important to him, and he relied on it to determine his code status. He reviewed the highs and lows of his life and identified what gave it purpose.
I invited the patient to determine how God spoke to him during his reflections about code status. After follow-up visits, the patient changed his code status to DNR – because he realized that the full code option would have been for his family instead of himself. As I listened, I learned that chaplains could engage in patient-centered discussions that assess motivations, build relationships, and provide patients and families the time to process information.
Discussions with patients about code status confront the most important realities of life, death, and dying. We respect the philosophical and spiritual actualities that may surface. This means that every member of the interdisciplinary care team must see the patient as a person. Patients can’t be convinced or coerced to choose a specific code status. It’s important to educate and support patients’ choices, but it’s also vital to reassess and revisit goals of care and treatment preferences (like code status) during hospitalizations.
Although conversations about code status can be difficult, they create opportunities to address significant spiritual and emotional concerns. This may be the first time that patients are asked about their understanding of where they are with their illness. It may also be the first time patients feel valued during a chronic disease and are invited to name their feelings. Or it may be an invitation for patients to exercise agency. A conversation about code status is sacred because it honors and respects the person, whether they choose full code or DNR.
Nicholas Perkins, BCC, is a palliative care chaplain for Franciscan Health in Dyer, Indiana.
