Code Status: Determining Life Saving Measures to Attempt

By David Zientek, MD, and Tom Caven, MD

Case Report

A 78-year-old homeless male was admitted to the intensive care unit with pneumonia, sepsis and renal insufficiency. He required intubation in the emergency department and remained minimally responsive despite minimal sedation. He had been admitted to the hospital one month earlier with a large cerebrovascular accident and had residual dense left hemiparesis and difficulty swallowing.

On his prior admission, despite extensive search, no family or designated decision-maker could be identified. The patient’s neurological status was deemed irreversible by his primary physician and a neurology consultation. The ethics committee was asked to review the case regarding the question of whether the patient might be appropriately assigned a “do not resuscitate” status. The committee agreed with this plan. Does this change in code status allow for withdrawal of antibiotic treatment or nutrition and hydration?

Advance Directives

Advance directives have become a common part of the medical landscape in the past 30 years. The purpose of these directives is to extend patients’ autonomy and allow them to specify their wishes in the event that they lose the capacity to make healthcare decisions in the future. The typical form of the directive in Texas allows the patient either to request that physicians withdraw life support measures if the patient has been certified as having a terminal or irreversible condition or to request that all life-sustaining measures be continued.

An irreversible illness is one that can be treated, but never cured. The patient would be unable to care for or make decisions for himself, which would be fatal without life-sustaining measures. Terminal illnesses are those that are expected to lead to death within six months, even with life sustaining treatment. According to Texas law, artificially delivered nutrition and hydration are considered life-sustaining treatment. Cardiopulmonary resuscitation may also be considered a form of life-sustaining treatment.

In the absence of an advance directive, or if the patient’s condition does not fit those specified by the directive, the patient may also specify in advance a surrogate decision-maker to make healthcare decisions when the patient does not have capacity to do so (Medical Power of Attorney). If no one has been identified as the Medical Power of Attorney, family members may act as decision-makers in a hierarchy specified by law, which typically includes the spouse of an adult, followed by reasonably available adult children, parents or nearest living relative. For a child, the parents would be the first choice. In the absence of an identified surrogate or any available family (after appropriate attempts to locate them), under certain circumstances physicians may make decisions for the patient who lacks capacity to make a healthcare decision.

According to Texas law, if there are no surrogate or family decision-makers for a patient who has been certified in writing to have a terminal or irreversible condition, the attending physician may withhold or withdraw life-sustaining measures with the concurrence of another physician who is not involved in the patient’s treatment or who is a member of an ethics or medical committee of the treatment facility. As an added protection for patients in this vulnerable position, the Seton Family of Hospitals requires an ethics committee consultation that includes at least one physician member of the ethics committee who is not involved in the care of the patient before withdrawing life-sustaining measures in these situations.
As noted, there are a variety of life-sustaining measures to consider at the end of life. Patients may wish to forego CPR, but continue other forms of treatment such as antibiotics or intravenous vasopressor agents. The various levels of “code status” within Seton outlined below allow patients to specify in greater detail those life-sustaining measures they wish to forego and those they wish to pursue. Thus, a decision to forego CPR, as in our case, does not necessarily imply that it is appropriate to withdraw all other forms of life-sustaining care unless these are explicitly addressed.
The issue of artificially delivered nutrition and hydration requires additional comment. The “Ethical and Religious Directives for Catholic Health Care Services” that guide care at all Catholic sponsored hospitals in the United States specifies that:

There should be a presumption in favor of providing nutrition and hydration to all patients including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.

In light of this statement, nutrition and hydration should be continued unless, after discussion with the patient, the surrogate or the ethics committee in the absence of surrogates, it is determined that continued nutrition and hydration would be a burden to the patient. In the case presented, nutrition and hydration should be continued unless it is determined that there is significant burden to the patient such as recurrent aspiration, refractory diarrhea that may lead to recurrent bedsores, inability to assimilate the nutrition or significant discomfort from the feeding tubes. In particular, in light of a recent allocution by Pope John Paul II and comments by the Congregation for the Doctrine of the Faith, patients with the persistent vegetative state should continue to receive artificial nutrition and hydration unless there is clear harm being done to the patient by their continued provision.

Categories of “Code Status” specify in advance what specific life-saving measures will be attempted in the case of a cardiopulmonary arrest. Ordinarily the patient makes his or her own decision, but, as noted in the earlier example, this may not be possible in certain circumstances, and surrogate decision-makers (occasionally including the ethics committee) make the choice.

Category I is “Full Code:” all resuscitative measures are employed including chest compressions, intubation, electrical cardioversion, medications, volume expanders, blood products, oxygen, etc.
Category II is “Limited Support:”
- Category IIA (previously the “Chemical Code”): NO chest compressions and NO intubation. However, vasopressors, antiarrhythmic drugs, electrical cardioversion, noninvasive mechanical ventilation, plus IV antibiotics, oxygen, blood products and volume expanders are permitted
- Category IIB: NO Intubation, NO chest compressions, NO antiarrhytmic drugs, NO vasopressors and NO electrical cardioversion. However, IV antibiotics, blood products, volume expanders and oxygen are permitted.
Category III is “Comfort Support:” NO resuscitative measures at all. Employ palliative measures to increase patient comfort and dignity.

Previously instituted measures do not require withdrawal, but critical care admission cannot take place under this code status.
The careful monitoring of the Code Status categories allows physicians, nurses and other caregivers to make thoughtful decisions in advance, to balance the wishes to “do everything possible” with the realities of a medical situation in which further attempts at resuscitation can only prolong suffering without chance of recovery. Ideally the Code Status should closely follow the plan of care. For example, if palliative care is the treatment plan, it is unlikely that a patient would remain at a level of Category I for Code Status. The process of guiding patient and family through these extremely important, emotional and difficult choices can benefit greatly from the assistance and experience of the palliative care team as early in the course of care as practical.