After a week or so on the wards, my resident sat down and taught us how to get the Code Status from patients. It’s required that every patient be asked their code status, of course, and it was always a bit awkward that I would spend 40 minutes getting to know the patient, and then after I left, my intern or resident would see the patient for two minutes and quite informally ask them about DNR/DNI. Needless to say, the patients were always somewhat taken aback. “The medical student didn’t say anything! Am I going to die?! Are you expecting me to need to be intubated?” So my resident decided that it would be best if we learned how to get the code status, so that it could just be a part of our spiel. We practiced with each other and had a pretty standard speech set and ready to go when I would need it.
All I knew about my patient was that she was an 82 year old female who had an atrial fibrillation episode with a rapid ventricular rate. She was Russian, she told me in broken English after I walked in and introduced myself. No problem. I picked up the phone, dialed in the Russian language line, and we started having our conversation. The history went really well, even with the awkward pauses as we each waited for the interpreter to translate. In the middle of our conversation, I got a page from my resident - “Don’t forget to get the code status!!” After the initial butterflies and a couple of deep breaths, I reassured myself that I could do it. I'd practiced with my resident, with standardized patients - how hard could it be on a real live person?
So I pulled out the pre-written speech that my resident had given me, and I started my code status spiel. “Lastly, this is a question we ask all of our patients who are admitted into the hospital. Now, we think you’re going to be fine, but in case of an emergency – specifically, if your heart stopped or you had such difficulty breathing that you’d need a breathing tube or ventilator, what would you want us to do?”
She was smiling as the translator translated. And then as more of it got translated, confusion and shock took over. “You’re my physician! I came to the hospital to be taken care of by you!”
I reassured her that we would of course take care of her. I explained to her what we normally do during a code status, adding at the end, “so I’m just asking if you had wishes or beliefs contrary to this.”
She spoke rapidly in Russian with the translator.
The translator then broke from her translator role and told me that in Russian culture, it is taboo to talk about possible life-threatening situations, as my patient thought that it was essentially inviting in the devil. My patient didn’t want to make this decision, since she felt it was the doctors’ responsibility to determine whether to do everything or let her go.
I apologized, and ended the encounter as gracefully as I could.
When I went back to the team room and relayed the whole story to my resident. He nodded understandingly, told me to review her chart and said, “and if there’s nothing, just put her down as Full Code.”
She had never been to our hospital before, so there were no records for her. So, like a lemming, I did as I was told, and put her down as full code.
Two weeks later, I had a class on difficult discussions, and the issue of obtaining DNR/DNI status was brought up. We were told to never use specifics - don't ask about their heart stopping or breathing cessation, and NEVER ask if they want the care team to do everything. And of course, never assume anything. And NEVER go in alone.
I had done everything wrong.
Luckily for me, nothing happened. Her hospital stay was uneventful and she went home the next afternoon. But I can't help worrying about the Full Code status that is now in her chart. Because, chances are that she will return to the hospital with yet another heart issue, and another med student will interview her and she will again refuse to make a DNR/DNI decision, and some resident will tell that med student to review the charts. And there it will be - FULL CODE.
3 years ago
