Managing Code Status Discussions

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

Step 1: Assess Decision-Making Capacity

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

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

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

Step 3: Define and Document Code Status Options

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.

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?

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

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