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What Is an “Appropriate Code”?

Some of the blame, however, must rest with clinicians, as we have sometimes acted and spoken as if it were different, in ways that it is not. When we act on a perceived obligation to offer this procedure even when we feel it cannot help the patient, we treat it differently, and send that message clearly to our patients and their families. Our role as physicians is not to feed into false impressions learned from television or the movies. If a patient or family believes that CPR can save everyone, or that antibiotics cure the common cold, the best response is not to begin (or offer) ceftazidime, but to educate in a compassionate manner. Of course, end-of-life decisions loom large. They require sensitivity and flexibility on our part, and we need not always have our way. And, importantly, the approach whereby only potentially helpful treatments are made available requires a healthy dose of professional humility. This requires that we admit what we do not know, to ourselves, our patients, and their families. Are we certain that CPR cannot benefit the patient? If there is a reasonable chance it could, then patients or their families deserve an honest choice, in which there should be no room for faking it. If an attempt at CPR is then agreed upon, it should be carried out in good faith, as part of a genuine effort to restore vital signs. Physicians often misunderstand the rules of their hospital and the laws of their state with regard to CPR, sometimes believing in a requirement where there is none. Every physician and nurse should be familiar with the requirements where they practice. If there is a rule or law that patients or their surrogate decision makers must be offered treatments that will not benefit the patient, then physicians and nurses should work to change it. Who better? The article by Lantos and Meadow provides thoughtful insight into care of dying patients and their families. The message regarding the need for flexibility in our approach to the family, and the conduct of the code itself, is well received. The premise that CPR must always be performed unless families have agreed to DNR, however, is mistaken. Thus, the rationale for a slow code that is not a good-faith effort to restore vital signs is lost. The decision to offer any procedure should be based primarily on the degree of certainty that it will benefit the patient. For any treatment, including CPR, if there is a reasonable chance it could help the patient and the informed patient or family requests it, the clinical team should put forth the team’s best effort to make it work. If the anticipated benefit to the patient is so low that the physician plans a feigned effort, it would be preferable not to offer it. If CPR cannot benefit the patient, the physician should not offer it, nor put families in the difficult position of having to agree to an order not to provide it. That is the least bad solution.