Mastering the Code Status Conversation
It can be difficult to hear as a patient or family member, and it can be equally uncomfortable to start the conversations as a provider around resuscitation status. Effective communication strategies for broaching code status and resuscitation discussions rely on a step-wise, compassionate, and goal-oriented approach. There are some simple strategies that can be followed to have these discussions, as much as possible, before a patient is critically ill, scared, and not cognitively at their best, in the hospital.
1. Preparation and Setting the Stage
Ensure physical comfort and privacy: Sit down at eye level next to the patient, ensure a private environment, and ask if family members or support persons should be present.
Self-reflect before entering: Clinicians should pause to assess their own emotional state, fatigue, or time constraints so that haste does not negatively impact the discussion.
Establish personal connection: Take a moment to learn about the patient as a person (e.g., asking about their life outside the hospital) to build trust before bringing up sensitive medical decisions.
2. Normalizing and Contextualizing the Topic
Frame as routine care: Introduce the discussion as a standard topic addressed with all admitted patients regardless of how healthy or sick they are.
Reassure the patient: Explicitly clarify that bringing up code status does not mean their condition is worsening or that death is imminent.
Initiate discussions early: Research indicates that most patients (84%) are open to discussing DNR orders and prefer to have initial conversations while still healthy, ideally in an outpatient office or home setting with their primary physician.
3. Assessing Understanding ("Ask-Tell-Ask")
Use the "Ask-Tell-Ask" framework: Start by asking what the patient understands about their illness, explain any missing or corrected information clearly, and ask again to verify their comprehension.
Ask open-ended questions: Encourage the patient to do most of the talking by using open-ended openings like *"What do you understand about your current health situation?"* or *"What have you heard about resuscitation orders?"*
4. Exploring Goals, Values, and Expectations
Focus on broader goals before procedures: Ask patients about their expectations and priorities for the future ("What goals do you have for the time you have left; what is important to you?") before introducing specific medical interventions.
Uncover underlying values: Ask clarifying follow-up questions such as "Can you explain why you feel that way?" to understand the values driving their choices.
Identify a surrogate decision-maker: Ask the patient to designate a legal healthcare surrogate and encourage them to discuss their care preferences directly with that person.
5. Using Clear Language and Providing Realistic Information
Avoid euphemisms and vague phrasing: Never ask "Do you want us to do everything?", as "everything" is easily misinterpreted and implies that choosing DNR means receiving suboptimal care.
Describe CPR accurately as a package: Explain CPR plainly, including chest compressions, electrical shocks, and mechanical ventilation, rather than presenting it as a menu of options.
Share realistic outcomes: Provide accurate survival data (e.g., explaining that roughly 10–15% or 1 in 7 patients who receive in-hospital CPR survive to discharge) to address widespread public overestimation of CPR success.
Differentiate DNR from overall treatment: Reassure patients that a DNR order strictly applies to halting CPR if their heart stops; it does not stop active treatment, symptom control, or pain management for their underlying illness.
6. Offering Clear Medical Recommendations
Seek permission: Ask before giving professional advice ("Can I make a recommendation about how we should approach your care if your condition worsens?").
Lead with affirmative care: Always explain what will be done for comfort, dignity, and symptom management before discussing interventions that will not be attempted.
Provide goal-aligned guidance: When CPR will not achieve the patient's stated goals or prognosis, frame the DNR choice as a direct medical recommendation rather than placing the burden of "choosing" solely on the patient or family.
7. Managing Emotions and Disagreements
Respond with empathy and silence: Use empathetic statements or supportive silence when patients or families display strong emotional reactions.
Explore drivers of CPR requests: Persistent requests for CPR often stem from unrealistic expectations, fear of loss, guilt, feeling a moral obligation not to "give up", or system distrust[26]. Address these emotions directly and refocus on overall values rather than arguing over procedures.
8. Establishing a Plan and Documenting
Outline the broader care plan: Clarify overall care goals and orders beyond the DNR decision.
Revisit as needed: Let the patient know that code status preferences can be re-evaluated and updated as their medical situation evolves.
There are times when we can’t avoid those emergency discussions, as terrible things happen, but it should be a standard discussion with annual primary care visits, and a conversation with family and close friends should be encouraged for all patients. So take the time, normalize the conversation, and allow everyone the chance to have a choice for their end-of-life care, and involve the loved ones that they choose to include.
