Resuscitation à la Carte: Ethical Concerns About the Practice and Theory of Partial Codes

Does Reframing Do-Not-Resuscitate to Beneficial Care Only Increase Acceptance of No-CPR Orders?

BACKGROUND

The terminology of a do not resuscitate (DNR) order can be confusing and controversial for patients at the end of life. We examined whether changing the name to beneficial care only (BCO) would increase patient acceptance.

RESEARCH QUESTION

Would individuals be more willing to forgo full code (FC) status and accept a no-CPR order if the order title was BCO?

STUDY DESIGN AND METHODS

We conducted a cross-sectional survey of 599 adults residing in the United States, presenting participants with a hypothetical scenario of a terminal patient. One-half were given a choice between FC and DNR status, and one-half were given a choice between FC and BCO status. The 20-item survey included multiple-choice responses and 1 free-response question.

RESULTS

In our nationally representative survey of US participants who were 50% female and 26% non-White (99% response rate, 599 of 600), there was no difference in participant preference for BCO or DNR overall (P = .7616) and across participant sociodemographic characteristics. Although themes of participant reasons for choosing against CPR were similar for both DNR and BCO preferences, including harms imposed by CPR, lack of quality of life, trust in the medical team, and avoidance of suffering, 2 additional themes appeared only for BCO responses, including CPR would be useless and the patient would continue to receive beneficial care.

INTERPRETATION

We found no statistically significant difference in preference between BCO and DNR orders for a terminally ill patient. These findings suggest changing the terminology of DNR to BCO may not lead to changes in decisions to forgo CPR. The additional themes identified with the use of BCO support the concept that BCO terminology conveys to the recipient that all beneficial care will continue to be provided to the patient.

Demystifying Limited Code: Standardizing Resuscitation Options in a Large Health Care System

Upon admission to an acute care hospital, patients and families are faced with determining their cardiopulmonary resuscitation status during conversation with providers. Medical providers are tasked with providing education and options in the context of the patient's acute and chronic conditions. Misconceptions are common in the general public, and providers may struggle with providing guidance in high-stress situations. Literature review revealed a lack of national consensus on code status definitions. Electronic health records may include multiple options for code status orders, which may lead to confusion for patients and medical staff, resulting in provision of potentially ineffective or undesired medical care. The following discussion will examine multiple cases in a large health care system and a novel way of standardizing resuscitation options using Havelock's change theory. This quality improvement project was approved by the institutional review board.

No More Resuscitation a la Carte: Towards a Universal, Simple, Ethical, and Medically Sound Code Status Ordering

Cardiopulmonary resuscitation is a commonly performed intervention in clinical medicine and determining a patient's code status is paramount. "Limited/partial code" has crept into medical practice throughout the years and has become an acceptable practice. We describe here a tiered, clinically sounds and ethical code status ordering that includes the main elements of resuscitation, helps with establishing goals of care, eliminates the use of "limited/partial code," facilitates shared decision-making with patients and surrogates and is easy to communicate to healthcare team members.