“Would you want us to do compressions if your heart were to stop?” I asked.  

“Of course!” the patient said.

“Would you want a breathing tube if you needed help breathing?” I asked.

“Yes, do everything you can,” the patient said.

“Ok, we call that ‘full code.’ If your heart were to stop, we will do what we can to bring you back,” I said.

“To my surprise, I recently learned that there are people who don’t want that,” the patient said.

“Correct,” I said. It was a busy day and given that the patient’s personal goals regarding code status were quite clear I avoided further discussion. 

~

Code status is the first decision people make regarding their goals of care. “Code” is medical slang for a heart attack (which is when the heart stops causing death). “Goals of care” is an umbrella title for the objectives patients have when they interact with the health system. Goals of care exist because patient autonomy is a key ethical principle in medicine. “Patient autonomy” is the idea that patients have the right to information about their care options (the risks and benefits of all the options) and have the right to decline any medical intervention they wish even if declining can result in a sooner death. 

We always ask code status when patients are admitted to the hospital so that we know what the patient would want if the unexpected happens. There are 3 code status options:

• “Full code” means that a person would like compressions and a breathing tube if their heart stops.
• “DNR/otherwise full interventions” means a person does not want compressions if their heart stops but would want other interventions (like a breathing tube) if they needed them for some other reason.
• “DNR/DNI” means that a person does not want compressions or a breathing tube at any time.

Unlike what the patient above believed, picking a code status is not an easy decision for many individuals. There are zillions of reasons why one’s heart might stop; the likelihood increases the older a person gets and the more medical problems they have. There are also multiple situations that might cause young, healthy people to code. A common trajectory (but by no means the only one) for code status is that young people choose to be full code and as people get older (like in their 70s or older) and/or sicker they decide to change to DNR/DNI. If a person doesn’t pick a code status, the default is always full code.

If you ever find yourself in the situation where you are very old and frail and/or very sick your medical team might encourage you to consider changing your code status from full code to DNR/DNI. Some individuals and families are against the idea of DNR/DNI and that is their right. However, let me explain why your healthcare team might recommend DNR/DNI and why the decision is more delicate than it might first appear.

When someone codes it means that their heart stopped; they are dead. The chance of coming back to life after someone’s heart stops is zero if nothing is done. If efforts are made to restart their heart (like compressions, possible shocks, possible breathing tube) then they might come back to life or they might remain dead. The chance of coming back to life if something is done depends on many, many factors. And, even if we can get someone’s heart to restart after it stops, we can’t guarantee that the person will wake up or have brain function again. Medicine is imperfect; we can “save life” and “prolong life” but the nature of that life ranges from fully functional to a vegetative state (dependent on a ventilator and unable to communicate).

The likelihood of someone fully recovering from a code after we get them back depends on how strong and healthy they were before their heart stopped and the reason they coded. It also depends on how long it took us to restart their heart. For example, returning to normal function after coding is more likely in an otherwise healthy person who coded because they had an abnormal heart rhythm and whose heart restarted rapidly after initiating compressions. A full recovery is less likely in a person who has multiple medical conditions and required an hour of compressions before their heart restarted.

Compressions and post-code recovery are invasive medical interventions. For example, compressions often cause rib fractures. Many people require at least several days with a breathing tube and on a ventilator after their heart restarts. This is why, as you may have noticed in the above code status options, there is no option to have compressions without accepting a breathing tube (while you can have the reverse). The reasoning is that there is no point in doing compressions if a person does not want the interventions required to keep them alive after we restart their heart.

An important reason that people choose DNR/DNI over full code is because they believe their chance of surviving and returning to a functional state after a code is low. Often people who choose to stay full code no matter how sick they are do so because they believe any life is worth living. To complicate matters further, a person (or their appointed medical decision maker) can change their code status at any time. The fluidity of code status is why we ask code status every time a person comes to the hospital. Like most things in medicine, there is no “one-size-fits-all” for code status. Choosing a code status is a very personal decision with no right or wrong answer. The decision often depends on an individual’s values about life, beliefs about what happens after death, and baseline state of health.