how to “advance” a code status - perelman .ppt

How to Discuss CPR and make a recommendation Dr. Joshua Uy University of Pennsylvania Case HS 93 yo male Cognitively intact Class IV D CHF, hypotensive (syst 80’s-90’s) Stage 4 CKD, swollen legs to waist Recent hospitalization for CHF flare Glaucoma, Pacemaker, afib, s/p Aortic valve replacement, severe spinal stenosis Wants to know if he is eligible for a kidney or heart transplant. Case HS Full Code When asked why? “I want to live” “Go out fighting in the ICU” Case HS Question 1 Would you make a recommendation for DNR? A. Yes B. No Case HS Question 2 What would your next step be? Case HS Question 3 What survival rate would you quote? A. 0% B. 1% C. 5% D. 10% E. 20% Goals of the lecture Physicians will have more flexibility in communicating about CPR Patients will have a code status that reflects a good fit with their goals, values, understanding and efficacy Outline Focus on outcomes Review outcomes of CPR Discuss communicating the outcomes Health literacy Values How to make a recommendation Shared decision making Scripts What is a code status? Refers to when someone is dead Not breathing, no pulse Two options: Full or none Caveats….Shocks only? ICD only? Witnessed? Does not refer to When someone is alive Limits on life sustaining treatment i.e. ICU care, dialysis, major surgery, PEG’s Beyond code status Alive (Advance care plan) Dead (code status) Curative care Full Code Curative care DNR/DNI Palliative care DNR/DNI Palliative care Full Code* Trying to cram everything into DNR/DNI is not possible. DNR may suggest palliative goals but not always *This is a frustrating situation What is CPR? Intubation Chest compressions Electrical shocks Medications via vein or endotracheal ICU care on a vent (often) What are the clinical outcomes? Immediate death Person does not survive the code Prolonged death in the hospital Due to cardiogenic shock or anoxic encephalopathy Survival with impairment Institutionalized, dependent Survival at or near baseline status Ef