managing-code-status-discussions

# Managing Code Status Discussions

Documents goals-of-care conversations with code status decisions and advance directive alignment for hospitalized patients.

## Why This Skill Exists

Code status discussions are among the most clinically and legally consequential conversations in hospital medicine. Studies show that only 30% of hospitalized patients have a documented code status discussion, yet 70% of patients who undergo in-hospital CPR do not survive to discharge, and among those who do, many suffer significant neurologic impairment. The Patient Self-Determination Act (1990) requires hospitals to inform patients of their right to create advance directives, and The Joint Commission requires documentation of advance directive status in the medical record.

Inadequate code status documentation is a leading cause of unwanted medical interventions, patient and family distress, and medicolegal liability. When code status is not clarified, the default is Full Code — which may not align with the patient's values, prognosis, or advance directive. Hospitalists conduct more goals-of-care conversations than any other specialty; structured documentation protects patients' autonomy and provides legal clarity for the care team.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

Before initiating a code status discussion, confirm:

1. Does the patient have an existing **advance directive**, **POLST/MOLST**, or **healthcare proxy/durable power of attorney**? *(Default: Check medical record and ask patient/family)*
2. What is the patient's **current code status** in the EMR? *(Default: Full Code unless otherwise documented)*
3. Does the patient have **decision-making capacity**? *(Default: Assess using the four-component capacity evaluation)*
4. If the patient lacks capacity, who is the **legally authorized surrogate decision-maker**? *(Default: Follow state-specific surrogate hierarchy)*
5. What is the patient's **prognosis** and current clinical trajectory? *(Default: Per attending assessment)*
6. Are there **cultural, religious, or spiritual considerations** that affect the discussion? *(Default: Ask the patient/family; engage chaplaincy if requested)*
7. Has the patient or family expressed any **prior preferences** about end-of-life care? *(Default: Review prior notes, social work assessments)*
8. Is there **clinical urgency** — is the patient actively deteriorating and code status discussion cannot wait? *(Default: If yes, involve attending and ethics if needed)*

### Documents to Request

- Advance directive or POLST/MOLST form (if it exists)
- Healthcare proxy or durable power of attorney documentation
- Prior goals-of-care notes from previous admissions
- Palliative care or ethics consultation notes
- Social work psychosocial assessment
- Chaplaincy notes (if spiritual care involved)
- State-specific surrogate decision-maker hierarchy reference

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## Step 1: Assess Decision-Making Capacity

Before any goals-of-care discussion, evaluate the patient's capacity using the four-component standard:

| Component | Assessment Question | Documentation |
|-----------|-------------------|---------------|
| **Understanding** | Can the patient explain the medical situation in their own words? | "Patient states: [quote]" |
| **Appreciation** | Does the patient recognize how this situation applies to them personally? | "Patient acknowledges [condition] affects them by [statement]" |
| **Reasoning** | Can the patient weigh options and explain why they prefer one over another? | "Patient reasons that [explanation of tradeoffs]" |
| **Expression of choice** | Can the patient clearly state a consistent decision? | "Patient states preference for [choice]" |

**Key principles:**
- Capacity is decision-specific — a patient may have capacity for some decisions but not others
- Capacity can fluctuate — reassess when clinical status changes (delirium, medication effects)
- Disagreeing with the physician's recommendation does not indicate lack of capacity
- If capacity is uncertain, request psychiatry or ethics consultation

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## Step 2: Conduct the Goals-of-Care Conversation

Use the REMAP framework (developed by VitalTalk):

### R — Reframe
"I'd like to take a step back and talk about the big picture of your care."

### E — Expect Emotion
Allow silence. Respond to emotion before returning to information.
- "I can see this is difficult."
- "It's okay to feel overwhelmed."

### M — Map Patient Values
Ask open-ended questions to understand what matters most:
- "What do you understand about your current condition?"
- "When you think about the future, what is most important to you?"
- "Are there things you would not want — treatments that would be worse than the illness?"
- "What gives your life meaning and quality?"
- "Have you ever seen a loved one go through a serious illness? What did you learn from that?"

### A — Align with Values
Reflect back what you heard:
- "It sounds like being able to [value] is most important to you."
- "You've told me that you would not want [specific treatment] if it meant [specific outcome]."

### P — Plan Treatment to Match Values
Make a recommendation based on the patient's stated values:
- "Given what you've told me, I would recommend [code status] because it aligns with your goal of [value]."
- Never present code status as a menu of checkboxes — frame it in terms of the patient's values and prognosis

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## Step 3: Define and Document Code Status Options

| Code Status | Definition | Includes | Does Not Include |
|-------------|------------|----------|------------------|
| **Full Code** | All resuscitative measures | CPR, intubation, vasopressors, defibrillation, ICU transfer | — |
| **DNR only** | No CPR if pulseless | All other interventions including intubation, ICU | Chest compressions, defibrillation |
| **DNR/DNI** | No CPR and no intubation | Medications, non-invasive ventilation (BiPAP), IV fluids | Chest compressions, defibrillation, endotracheal intubation |
| **Limited intervention** | Focused medical treatment | IV medications, antibiotics, non-invasive ventilation | ICU transfer, invasive procedures, vasopressors |
| **Comfort measures only (CMO)** | Symptom management only | Pain control, anxiolytics, positioning, oral care, family presence | Diagnostic tests, IV medications (except comfort), lab draws |

**Critical documentation point:** Specify what IS included, not just what is excluded. "DNR/DNI" alone is insufficient — document whether the patient wants IV antibiotics, vasopressors, or ICU transfer.

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## Step 4: Document the Conversation

Use this structured documentation format:

```
GOALS-OF-CARE / CODE STATUS DISCUSSION

Date/Time: [Timestamp]
Participants: [Patient, family members by name and relationship, 
              healthcare team members]
Interpreter used: Yes/No — language [specify]

Decision-making capacity: [Present / Absent — cite assessment]
Decision-maker: [Patient / Surrogate — name, relationship, legal authority]

Discussion summary:
- Patient's understanding of current condition: [Document in patient's words]
- Patient's values and priorities: [Specific statements]
- Prognosis discussed: [What was communicated about expected outcomes]
- Code status options discussed: [Which options were explained]
- Patient/surrogate questions: [Summarize]
- Recommendation made: [Physician's recommendation with rationale]

Decision:
- Code status: [Full Code / DNR / DNR-DNI / Limited Intervention / CMO]
- Specific inclusions: [List what patient wants]
- Specific exclusions: [List what patient declines]

Advance directive status:
- Existing AD on file: Yes/No
- POLST/MOLST completed: Yes/No
- Healthcare proxy designated: Yes/No — [Name]

Follow-up plan: [Reassess at [trigger], palliative care consult, 
                 family meeting scheduled for [date]]
```

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

After completing a code status discussion:

1. Is the **code status order** in the EMR consistent with the documented discussion?
2. Are **specific limitations** (e.g., "DNR but wants trial of BiPAP") clearly documented?
3. Has the **surrogate decision-maker** been identified and documented if the patient lacks capacity?
4. Is there a plan for **reassessment** if clinical status changes?
5. Has **palliative care** been consulted for complex or conflicted cases?

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## Quality Audit

- [ ] Decision-making capacity is assessed and documented before the discussion
- [ ] Surrogate hierarchy is followed if patient lacks capacity (state-specific)
- [ ] Goals-of-care conversation is documented with patient/surrogate's own words
- [ ] Code status order matches the documented decision
- [ ] Specific inclusions and exclusions are listed (not just a category label)
- [ ] Advance directive or POLST status is verified and documented
- [ ] Prognosis was communicated with appropriate honesty and empathy
- [ ] Cultural and spiritual considerations were addressed
- [ ] Interpreter was used for non-English-speaking patients or surrogates
- [ ] All participants in the discussion are documented by name and relationship
- [ ] Follow-up plan or reassessment trigger is defined
- [ ] Nursing is notified of any code status change
- [ ] Code status is visible on the patient's chart, wristband, and room signage per institutional protocol

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## Guidelines

- Never ask "Do you want us to do everything?" — this frames code status as a choice between care and abandonment
- Always make a recommendation — patients and families want physician guidance, not a menu
- Separate the goals-of-care discussion from the code status order — understand values first, then translate into medical orders
- Revisit code status when clinical status changes significantly (ICU admission, new terminal diagnosis, failure to improve after expected timeline)
- A patient can change their code status at any time — document each change as a new note
- For patients with existing advance directives, verify that the current clinical scenario matches the conditions described in the directive
- Involve palliative care early for patients with serious illness, not just at end of life
- Document disagreements between family members and the resolution process — consider ethics consultation for unresolvable conflict