Code Status and Life Sustaining Treatment
Tarsha K. Rodrigue
Saint Joseph’s College of Maine
HA 567: Nursing Home Operations
Philip DuBois
December 11, 2022
Abstract
Code status and life sustaining treatment decisions can often bring up ethical situations for residents newly admitted into a long term care facility. A significant event, such as a fall or a hospitalization may precipitate the admission to a long term care facility. It may also be a precursor to a health decline that results in the need to make other life sustaining interventions. Code status and life sustaining treatment questions can be difficult conversations for residents and their families to have at admission to a long term care facility. Long term care leaders and nurses should receive training on facilitating these discussions.
Code Status and Life Sustaining Treatment
Ethical situations frequently arise in long term care facilities. One of the most common is around end of life care. Unprepared family members can be left to make decisions regarding treatment options and code status for residents that are no longer able to make their needs known. Families are unexpectedly faced with making life or death situations that they are unprepared for. It is important for long term care facilities to include goals of care discussions early in a resident stay. Long term care leaders, medical staff, and nurses should receive training on having code status and life sustaining treatment discussions with residents and family members admitted to long term care facilities.
Ethics in healthcare is a complex topic. “It deals with the distinction between what is considered right or wrong at a given time in a given culture” (Markose et al., 2016). In medical decision making, ethics includes the doctor, hospital, and the caregivers. It can also include patients or residents that are no longer able to speak for themselves. Different cultures will make decisions which may not be shared by medical personnel. Caregivers in long term care facilities have an obligation to provide care that is going to promote health and alleviate suffering without doing harm (Shi & Singh, 2019). At end of life, decisions regarding life sustaining treatment, particularly in patients that are no longer able to speak for themselves, is a significant ethical issue. Family members and residents may be unprepared to discuss, or unwilling to hear when treatment is futile.
In regards to healthcare, patients have the right to make informed consent regarding their own treatment options (Shi & Singh, 2019). This is an ethical principle known as autonomy (Akdeniz, 2021). Advanced directives are a method that a resident can use to make healthcare and treatment options in advance. In end of life situations, residents may have reached a point that they are no longer able to make decisions or they lack capacity. In those situations, having a living will or advance directive can outline the decisions that the resident would have made if they could still communicate (Shi & Singh, 2019). Lack of an advance directive can significantly increase the risk of an ethical dilemma between the healthcare provider and the family of a resident.
There are several different types of advanced directives. Code status, or do not resuscitate (DNR) orders are common in long term care facilities. A DNR means that trained clinical staff will not attempt to revive a resident through CPR or artificial means when the resident has stopped breathing or when their heart has stopped (Shi & Singh, 2019). It can be hard for a family or a resident to decide not to proceed with CPR. This type of treatment can have low risk of success with significant negative side effects. Family members can feel as though they have not done enough to save a loved one’s life when they make the decision to change to a DNR.
A living will is a document that communicates a variety of the resident’s wishes regarding medical treatment and life sustainment (Shi & Singh, 2019). Although a living will does not cover all possible end of life and treatment scenarios, it will typically include both the utilization of a tube for feeding and the use of a mechanical ventilator for breathing. A durable power of attorney for the purposes of healthcare is a legal document. This document will appoint someone else to “act as the patient’s agent for purposes of health care decision making in the event that the patient is unable to unwilling to make such decisions” (Shi & Singh, 2019, p. 351). These are two other types of advanced directives.
According to Bollig et al., (2015) in a study of nursing home staff, 91% of nursing home staff described ethical complications as a significant burden in their work. One of the largest segments of ethical issues revolved around end of life issues (Bollig et al., 2015). The most significant challenges faced by healthcare staff providing care at end of life revolve around prolonging a resident’s life through the utilization of artificial hydration and nutrition, extensive treatment for a disease that has no cure, code status, and the utilization of mechanical ventilation (Aldeniz et al., 2021). It is important for nurses, providers, and care managers to be prepared to have conversations with families regarding code status and life sustaining treatment options. The initial conversations can prevent a more significant ethical dilemma.
End of life conversations can easily become complex ethical situations. An example could be when the resident is no longer able to speak for themselves and the family or power of attorney requests all care possible. This could mean a patient with dementia that is no longer able to walk, talk, or perform their own activities of daily living is being brought to podiatry and dentist appointments. Another example is when the resident has a clear advance directive, but the power of attorney or next of kin has reversed the decisions. Another more complex situation occurs when a resident does not have a next of kin, an advanced directive, and is unable to make their decisions known. These situations are all common at end of life or after a decline in health status results in a long term care facility admission.
Goals of care conversations at admission can greatly impact the number of ethical decisions that arise later in a resident’s stay in a long term care facility. Physicians and trained healthcare staff should have these conversations early, ideally when a resident is still able to make his/her needs known. Advanced life planning should be a standard topic between the physician, the care team, and the resident (Akdeniz et al., 2021). Information on the resident’s health status, the possible treatment options, and the impact of the treatment options on both quality and quantity of life could prevent challenging conversations at a later date (Akdeniz et al., 2021).
Specific training for code status and life sustaining treatment options is essential. According to Akdeniz et al., (2021) it involves “basic palliative care skills, such as person-centered and family-oriented communication skills, professional cooperation, and symptom management” (page 6). Physicians and clinical staff have an ethical and legal obligation to ensure that the resident and family participate in these challenging conversations. They deserve to be treated with dignity and respect. Having an interdisciplinary team prepared to have this type of conversation, in a gentle and compassionate manner, can have an impact on whether a situation becomes a more complex ethical concern.
Ethics committees can be a significant resource when an ethics concern arises. Most ethics committees are multidisciplinary and set up guidelines, policies, and procedures for organizations (Shi & Singh, 2019). Many ethics committees also include a member of clergy and legal counsel (Singh, 2023). They also serve in an advisory capacity when complex situations occur. Many ethics committees do not make decisions but instead serve in an advisory capacity to the medical team, resident, and family members.
Code status and end of life care are a challenging topic. When first moving into a nursing facility it is a difficult conversation for the care team to have with a new resident. It is important though, as it will establish the resident’s wishes in advance and may raise ethical questions early. This will allow the facility and interdisciplinary team to have follow up conversations, and potentially involve an organizational ethics committee early in the process. Having staff members trained to facilitate these discussions is essential. Families and residents need to feel assured that they are not giving up, or sacrificing their quality of life when making end of life care decisions.
References
Akdeniz, M., Yardimci, B., & Kavukcu, E. (2021). Ethical considerations at the end of life care. SAGE openmedicine, 9. https://doi.org/10.1177.20503121211000918
Bollig, G., Schmidt, G., Rosland, J. H., Heller, A. (2015, April 28). Ethical challenges in nursing homes –
staff’s opinions and experiences with systematic ethics meetings with participation of residents’ relatives. Scandinavian journal of caring sciences, 29(4), 810-813. https://doi.org.10.1111/scs.12213
Markose, A., Krishnan, R., & Ramesh, M. (2016). Medical ethics. Journal of pharmacy & bio allied
sciences, 8(1), S1-S4. https://doi.org.10.4103/0975-7406.191934
Shi, L., & Singh, D. (2019). Delivering healthcare in america; A systems approach (7th ed.). Burlington,
MA. Jones & Bartlett Learning.
Singh, D. (2023). Effective management of long-term care facilities (4th ed.). Jones and Bartlett Learning.
