Know Your Code Status
The most important thing to know about each of your patients.
What is the single most important thing you need to know about your patient, apart from their name?
Code status!
What do you do if you walk into your patient's room and find them unresponsive? You do not want to waste precious seconds trying to find out their code status. Keep reading to learn some important things to know about code status.
What is a code status anyway?
A patient's code status is an order written by an advanced provider specifying their wishes in the event of cardiac arrest (heart stops beating). Full code means that you will begin CPR if the patient is pulseless. DNR (Do Not Resuscitate) or DNAR (Do Not Attempt Resuscitation) means that CPR will not be initiated in the event of cardiac arrest.
What about DNI or other advanced directives?
DNI means do not intubate. If a patient's respiratory status were to deteriorate or they were unable to maintain their airway, a DNI means they do not want endotracheal intubation. However, they may be willing to accept less invasive means of rescue ventilation such as BiPAP so we will continue to proactively manage respiratory status with every available means except for intubation. Additionally, advanced directive may specify other life-saving or life-prolonging measures that a patient will or will not accept such as artificial nutrition or dialysis.
Patients with a DNR order do *not* receive less aggressive care for their condition.
A DNR order only means do not start CPR or other resuscitative measures for cardiac arrest. In every other way, they receive the same treatments as a patient who is a full code, unless they have specified otherwise in their advanced directives. If a patient with a DNR order is declining in their condition (e.g. lowered blood pressure, decreased level of consciousness), you should still notify the provider and/or call a rapid response according to your facility protocol. A patient can have a DNR order and be transferred to a higher level of care if they need it.
How do I know if my patient has a DNR order?
Most institutions will have a designated place in the active orders for code status. You should inquire about this on orientation. Some facilities will have additional policies that patients with an active DNR order will wear a DNR bracelet, and some patient care units may have a designation for DNR patients on their unit dashboard. Generally, DNR orders do not follow patients across different care settings, meaning that a patient who has a community DNR order, will still need a code status order entered by the provider on hospital admission. Likewise, a patient who chooses to be DNR while in the hospital will need a community DNR order at hospital discharge if they wish to be DNR if they have a cardiac arrest at home.
Is it the doctor's job to discuss a patient's code status with them?
Yes, a doctor or advanced practitioner has the responsibility of discussing a patient's code status with them. However, if you notice that a patient's code status does not match their stated wishes or advanced directives, it is your responsibility as a patient advocate to bring this to the provider's attention to clarify.