Med students guide to understanding code status

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Practical teaching from a student mentor in the general medical wards Hearing the words ‘code blue’ on the overhead pager can start your heart racing. But before you start chest compressions and jump in, you need to be aware of the patient’s code status. 

A code is called when a patient goes into cardiac or respiratory arrest. Code status refers to the level of medical interventions a patient wishes to have started if their heart or breathing stops.

A med student’s role during a code

Before you can understand code status, it is helpful to learn what causes a code and what your role is during resuscitation. Various medical conditions can lead to cardiac or respiratory arrest. Certain cardiac arrhythmias can make the heart beat chaotically, which prevents sufficient blood from getting to the heart. A person may also stop breathing due to a variety of conditions, such as shock, head trauma and severe respiratory infection.

Once a code is called, the code team goes into action. The team consists of a physician, nurses, respiratory therapist, lab tech and pharmacist. As a medical student, you will also be responding to code blues. Your responsibilities will vary. You are learning many aspects of patient care, so you will likely do whatever your supervising resident tells you.

You may have the opportunity to help the respiratory therapist intubate, which involves placing a breathing tube in the trachea. You may also start an intravenous line in order to administer medication, or you may perform CPR. In addition, be prepared to answer questions regarding which resuscitation medications to give.

In some situations, you may only get to observe. Several team members respond to a code, and the scene can become chaotic. Do your best to get involved and help out, but do not get in the way. Your supervising resident will provide you with direction as to what your role will be in each situation.

Determining code status

Before the team can spring into action, code status must be known and documented. When a patient is admitted to the hospital, they are asked if they wish to be a full code, which means all resuscitation interventions will be performed.

If a patient is a minor or unable to make their own medical decisions, the patient’s next of kin, such as a parent, adult child or spouse can state the patient’s code status. Patients can also legally designate a person to make their medical decisions in advance. This designee is called the power of attorney.

Some people also have their wishes written in a living will, which is a legal document stating what they want doing in the event that their heart stops. When a patient comes in through the emergency room and code status cannot be verified, treat them as a full code until other orders are written and confirmed by family members.

There are three types of code status a patient or family member may choose including the following:

Full code

A full code means a person will allow all interventions needed to get their heart started. This may include chest compressions and defibrillation to shock the heart out of a life-threatening heart rhythm. Placing a breathing tube in the airway to assist with ventilation and medications to treat the heart are all resuscitation interventions. Not all patients require each step. But if a patient is a full code, it means they are willing to allow any of the above measures.

DNR

A do not resuscitate (DNR) order is the opposite of a full code. A patient who is a DNR does not want any resuscitation measures taken. Patients who do not wish to be resuscitated must have a DNR order signed by a licensed physician in their medical record. Patients make themselves a DNR for a lot of reasons. Some may have a terminal illness or be elderly.

Limited code

A limited code is somewhere in between a full code and a DNR. A limited code means the patient wants some interventions, but not all. Limited code orders need to specify what the patient will allow and not allow. For example, some patients will only allow medications. When this is the case, the patient is said to be a chemical code only. Other patients do not want to be intubated, but agree to medications and CPR. Their orders will be written as a do not intubate (DNI). Make sure you understand what limitations the patient has in place before starting any intervention. 

Although it is not part of code status, medical students should also be aware that some patients who have a do not resuscitate order in place, also have orders for comfort care only. Comfort care means curative treatments and diagnostic tests are no longer ordered for the patient. Only intervention, which will make the patient more comfortable are given. These orders may be written for patients who are receiving end of life care.

Considerations

As a medical student, there are several things you should take into consideration about code status.

  • Medical students may sometimes think a do not resuscitate order limits other medical treatments. But that is not the case. DNR does not mean you do not treat the patient. Curative treatments, diagnostic tests and other procedures may still be ordered and performed.
  • Keep in mind, patients can change their code status at any time during their hospital stay. In some situations, patients who may have initially made themselves a do not resuscitate may have a change of heart. Up to date information on code status is part of the patient’s medical record and can be updated at any time.
  • If a family member asks you to explain something about code status or what measures are taken during resuscitation, you can use the opportunity to provide information and educate the family. But do not offer your opinion as to whether their family member should be a full code or a DNR. It is not your job as a medical student to get into the ethical or moral issues regarding code status.

 

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