Why Nurses Should Verify a Patient’s Code Status
Code status is one of the first pieces of information that nurses learn about their patients, but in a recent episode of the Ask Nurse Alice podcast, Nurse Alice shared a story that might make nurses think twice about verifying their patient’s code status.
Nurse Alice explained that in her job as a critical care transport nurse, there is a general unwritten rule that if you don't know your patient’s code status, they should be considered a full code. As she pointed out, it’s a lot easier to discontinue life support than bring someone back, so the strategy makes sense.
However, Nurse Alice encouraged all nurses to ensure that they speak to either the patient (if they can) or the designated healthcare decision-maker to double-check code status whenever possible. And she told a little story to illustrate just why that is.
This content used under license from "Ask Nurse Alice."
Always Check the Papers
Essentially, Nurse Alice was called in to transport a 95-year-old woman who was alert and oriented, not in a lot of pain, and on some oxygen, but had a significant medical history as well as trauma to her lungs, rib fractures, and a traumatic hemothorax—a dangerous combination that Nurse Alice knew could compromise her heart very soon. “Things looked like they could go south very soon and I was going to have to spend about 20 minutes in the ambulance with this patient getting her from point A to point B,” Nurse Alice described.
In other words, this woman was at a high risk for needing a full resuscitation and as far as the entire medical team was concerned, she was a full code. Until Nurse Alice happened to go through her paperwork—and found that she was actually a DNR.
When Nurse Alice brought up the paperwork to both the nurses and the doctor, no one was aware of it. They all admitted that they had not even spoken to the patient about her wishes nor checked the paperwork. One nurse even chided Nurse Alice that she should have asked the patient herself (despite the fact that Nurse Alice had only been on the case about 10 minutes instead of the nurse’s 12 hours).
And while staff can certainly get busy and paperwork can get missed, Nurse Alice pointed out that the DNR status on this patient was downright critical and could have changed the trajectory of her life dramatically.
“It frustrates me that we sometimes don't take the few minutes to do some exploratory work that can literally change the trajectory of someone's life,” she said. “That was so important. And that was all in her assisted living paperwork that came with her when she first arrived. No one looked at it at all. No one at the doctor. Not the nurses. They were just sticking it in the chart because she came with it.”
The bottom line? “You got to know the code status,” said Nurse Alice.
Beyond DNR
In addition to checking a patient’s DNR status, Nurse Alice also explained that there’s one other important piece of paperwork you’ll want to check on patients: the POLST, which stands for Physician’s Orders for Life-Sustaining Treatment.
The POLST is different from a DNR—a DNR is just the code status once the heart stops or breathing stops. A DNR dictates what you will do or not do if the patient stops breathing or their heart stops. A POLST, on the other hand, are portable medical orders for those who are seriously ill or frail.
Nurse Alice went on to explain that POLST orders are an approach to end-of-life planning based on conversations between the patients, the loved ones, and healthcare professionals. These discussions and the resulting decisions are based on the patient's values, beliefs, goals for care, their prognosis, treatments, alternatives, benefits and burdens to life-sustaining treatments.
“Basically, a pulse recognizes what the patient's wishes are for allowing a natural death to occur,” she said.
She added that a POLST can dictate things beyond just resuscitation such as: Do they want to be intubated? Or maybe they just want positive airway pressure. Do they want long-term tube feedings to help sustain nutrition? Do they not want them or do they only want to try it for a short period of time? This documentation allows people to make those decisions. Additionally, the POLST can dictate if a person requests not to be transferred to a hospital, but would like to continue care at home.
The POLST contains different parts, including: CPR status, about medical intervention details, nutrition preferences, comfort-focused treatment, and signatures that encompass important paperwork such as an advanced directive and healthcare agent. Nurse Alice reiterated that POLSTs are very important to have and if you notice that your patient does not have one, it’s a good opportunity to encourage them to fill theirs out.
“By having this document and knowing what this information is, you can make the best decisions for that patient,” Nurse Alice said. “You are going to save time, you are going to save money and resources and you’ll save a lot of pain, heartache and tears by doing this.”
“The worst thing you could do is have a patient who was DNR,” Nurse Alice added. “Maybe their heart stops, you initiate a code blue, you do everything. And the patient's family comes in and they're intubated, sedated on multiple drips in the ICU, just doing very poorly. Now the family is faced with the decision of withdrawing life support. Do you know how difficult of a decision that can be for a family when they could have allowed their loved one to pass naturally? Now they're going to carry this guilt.”
“It tears me up when I hear stories like this and so I thought it was really important for me to share this experience and share this story with you guys,” said Nurse Alice. “So just as a gentle reminder: please take a couple minutes to look that up in the patient's chart. I know y'all got a lot going on. I know you're overstaffed and overworked, but I promise that you doing this little bit of footwork ahead of time will make your job a lot easier, and really honor the patient and their best wishes.”
