Advanced Care
Planning: Code
Status
Travis Nesbit
Ucimc im pgy-1
Minilecture 1/15/2015
Objectives
Understand
Terminology
Advanced Care Planning (ACP)
Utilize
a POLST to better understand Code Status
POLST is not required to make code
decisions/orders!

Work 3 Example Cases
Gain
confidence in leading ACP discussions
ACP Terminology: Overview
Part
1: Documents
Question:
Part
what are two major ACP documents?
2: Acronyms
Question:
what are 4 major ACP acronyms?
ACP Documents: Advanced Directive
>=

18 yrs of age
future treatment
Appoints
a Health Care Representative
Does
not guide emergency medical personnel
Does
guide inpatient treatment decisions
ACP Documents: POLST
Physician
Orders for Life Sustaining Treatment
serious
illness at any age
current
treatment
Does
guide emergency medical personnel
***
Guides inpatient treatment decisions ***
***
Can serve as model for inpatient Code Discussion! ***
Accessing ACP Documents
CA Government approved Advanced Directive:
http://ag.ca.gov/consumers/pdf/AHCDS1.pdf
 Search terms (Google): “California Advanced
Directive”
CA Government approved POLST:
http://www.cdph.ca.gov/programs/LnC/Documents/MD
S30-ApprovedPOLSTForm.pdf
 Search terms (Google): “California POLST”
ACP Acronyms
Do
Not Resuscitate (DNR): Do not attempt to perform CPR or
any other life-restoring measures.
Do
Not Attempt Resuscitation (DNAR): Synonymous with DNR
Allow
Natural Death (AND): Definitions appear to vary; CA State
approved POLST uses it synonymously with DNR/DNAR.
Do
Not Intubate (DNI): Do not intubate under any circumstance,
code or not.
Hypothetical Case #1
Mr.
A is a 30 yr M with asthma presenting with PNA. He is speaking in
full sentences, but appears fatigued and his ABG shows a pCO2 of 50.
Dr.
K is a 28 yr resident who skillfully elicits a full-code status from Mr. A.
Hypothetical Case #1 cont.
Question
1: How would you document this decision in the chart?
Question
2: Although it's unnecessary in this instance, if you were to fill
out a POLST which sections would you check off?
Question
3: Would you consider filling out a POLST for this patient?
Hypothetical Case #2
Mrs.
Jones is also a 96 yr F with h/o 4V CABG, DM2, dementia,
multiple pressure ulcers, also presenting from SNF for AMS/fever. She
was also admitted by ED to MICU for Septic Shock; she is protecting
her airway, but delirious. She comes with an advanced directive
identifying her son Gomer as her decision maker.
Dr.
K this time is told by Gomer that his mom wouldn’t want to be
brought back after she passed, but if she needed a breathing tube
and it could be removed that’s okay.
Hypothetical Case #2 continued
Question
1: How would you document this?
Question
2: If we couldn’t find manual BP by cuff, and tele showed
wide complex polymorphic tachycardia to 200 bpm would you call
a rapid response or a code?
Question
3: Is this patient okay to intubate in a rapid response?
What about in a code?
Question
4: Would you consider filling out a POLST for this patient?
Hypothetical Case #3
Mrs.
Daisy is a 114 yr F with h/o 4V CABG, DM2 s/p bilateral
amputations, prosthetic hip, multiple pressure ulcers,
presenting from SNF for AMS/fever. Admitted by ED to MICU
for Septic Shock; she is protecting her airway, but delirious. She
comes with an advanced directive identifying her son Jeb as
her decision maker.
Dr.
K contacts Jeb. Jeb says she doesn’t want to be revived,
and no invasive breathing machines under any circumstance.
Hypothetical Case #3 continued
Question
1: How would you document this?
Question
2: If this patient had BP 55/33, confused, tachycardic to
180 bmp, and appeared to have respiratory distress would you call
a rapid response or a code?
Question
3: Is this patient okay to intubate in a rapid response? A
Question
4: Would you consider filling out a POLST for this patient?
code?
Summary

Know POLST and Advanced Directive

Know DNR, DNAR, AND, DNI
A
“code” and DNR status is for cardiopulmonary arrest.
DNR
DNI
and DNI are separate decisions.
applies to all circumstances, not just the code.
A
POLST can be a good model for your code discussion.
A
“code menu” is not necessary; see the POLST as an ex.
References
State of California Department of Justice, Office of the Attorney
General. http://ag.ca.gov/consumers/pdf/AHCDS1.pdf
California Department of Public Health.
http://www.cdph.ca.gov/programs/LnC/Documents/MDS30ApprovedPOLSTForm.pdf
UpToDate.com. http://www.uptodate.com/contents/advancecare-planning-and-advance-directives
Brigham and Womens Faulkner Hospital.
http://www.brighamandwomensfaulkner.org/about-us/patientvisitor-information/advance-care-directives/dnrorders.aspx#.VLhu_XvCf8M