no code codes

Presenter Disclosure
*no financial disclosures or conflicts*

Mitigating Potential Bias-
No commercial
interests

outline

• cases
• ethical considerations
• legal outcomes
• code comfort

case one
choking 83 year old in psych ward

case

• new admission with schizoaffective disorder
• dnar documented
• well until choked on evening sandwich after pills
• psychiatrist at bedside
• patient lying in bed, cyanotic, barely awake
• 'She is a no code!'

case 2
55 M with metastatic renal cell ca

case

• pt admitted for workup for dyspnea
• ESRD
• R pleural effusion
• VQ scan neg for PE
• consulted for symptom management, disposition
• sent to IR for US guided thoracentesis on medicine ward two days later

case cont'd

• called by resident as patient has acutely decompensated after procedure
• pt found to be gasping, cyanotic, hypoxic, unable to speak
• POCUS no slide on R hemithorax
• patient is a documented no code

What would you do?

Not about Slow Codes

Nevertheless, we believe that slow codes may be appropriate and ethically defensible in situations in which cardiopulmonary resuscitation (CPR) is likely to be ineffective, the family decision makers understand and accept that death is inevitable, and those family members cannot bring themselves to consent or even assent to a do-not-resuscitate (DNR) order. In such cases, we argue, physicians may best serve both the patient and the family by having a carefully ambiguous discussion about end-of-life options and then providing resuscitation efforts that are less vigorous or prolonged than usual
'Should the Slow Code be Resuscitated?'
Lantos et. al American Journal of Bioethics 2010

"We agree that physicians running a code should TAILOR the duration and medical interventions to each patient, but when all providers know the code should not even be initiated, the slow code only intensifies moral distress"
The False Dichotomy: Do 'Everything' or Give Up
Clark et. al
American Journal of Bioethics 2011

What does the CMPA say?

case one

• 41 disabled F with stage 4 breast cancer
• Extensive bone/lung mets
• Admitted for pain management

Untitled Slide

• Family physician unilaterally decides that resuscitation would be medically futile, makes her DNR.
• Patient dies 10 days later
• Sister makes College complaint as she was not consulted about DNR order

College findings

• agrees that resuscitation would have been futile
• cautioned physician to speak to SDM about DNR
• College further stated that the physician's reply to letter reflects his perspective that he did not need to consult with the family...and this does not meet the policy of the hospital nor the standard expected by the College

case two

• 73 F with IDDM has MI
• Pt goes into carcinogenic shock on ward, made no CPR with family agreement, in event of arrest
• MD documents DNR on chart, discontinues her insulin.

Untitled Slide

• pt becomes comatose due to hyperglycemia
• insulin re-started once recognized, regains consciousness
• pt dies several days later

Untitled Slide

• Family complains to College and launches legal action

The College determines that the physician interpreted the meaning of DNR too widely and cautions him "Do not resuscitate" does not mean withholding all treatment

In legal action, expert support cannot be found, case settled to patient's estate by CMPA on behalf of physician

CODE COMFORT IS LIKE A CODE BLUE, BUT THE AIM IS TO PROVIDE IMMEDIATE AND AGGRESSIVE RELIEF OF SUFFERING

'LIMITED INTERVENTIONS'

• Data from the National POLST Paradigm shows that only 50% of patients with a DNR order also choose comfort measures only.
• Need to determine full, limited, or comfort measures only

case one revisited

• patient becomes obtunded
• macgill forceps and deep suction with DL utilized to extract sandwich contents
• improvement with supplemental 02 and moxifloxacin

case two revisited

• 16 g angio cath placed in R hemithorax
• finger thoracotomy with small blade
• hi flow gentle BVM
• no improvement
• POCUS again, no PCE, no RV dilatation, standstill
• Pronounced in room, family contacted.

summary

• DNR is not DNI(intervene)
• Selected/limited interventions in patients may be the right/ethical thing to do
• Consider a CODE COMFORT approach to suffering
• We have a tricky job

questions?