shades of blue: the negotiation of limited codes by medical residents

SK. Sci. Med. Vol. 34. No. 8. pp. 885-898, 1992 Printed in Great Britain. All rights reserved

02779536192 S5.M) + 0.00 Copyright 0 1992 Pergamon Press plc

SHADES OF BLUE: THE NEGOTIATION OF LIMITED CODES BY MEDICAL RESIDENTS

JEXXA H. MULLER

Department of Family and Community Medicine, Box 0900, AC-9, University of California, San Francisco, San Francisco, CA 94143, U.S.A.

Abstract-One of the most difficult decisions facing physicians in contemporary medical practice is whether to initiate or withhold cardiopulmonary resuscitation (CPR) for patients who are critically ill. Because of the problems surrounding these decisions, hospital guidelines have recently been developed for the appropriate use of do-not-resuscitate (DNR) orders. Despite the establishment of these guidelines, problems with the application of DNR orders remain. This study examines one strategy used by internal medicine resident physicians to cope with the problematic nature of decisions regarding resuscitation-the use of partial or slow resuscitation attempts, known as ‘limited codes.’ It analyzes how these code efforts play a role within the context of resident work by enabling residents to circumvent ethical and practical dilemmas created by the circumstances of their clinical practice.

Key words-medical residents, do-not-resuscitate orders, limited codes, ethical dilemmas

INTRODUCTION

“Code Blue! Ward IOA!” The voice came urgently over the hospital public address system. Immediately doctors, nurses, medical students, and technicians, wheeling machines and resuscitation equipment, ran to the bedside of the man whose heart had stopped beating. In a bustle of frantic activity they began cardiopulmonary resuscitation-ripping open the man’s shirt, they electrically shocked his heart, inserted tubes into his nose, mouth and assorted veins, injected fluids, blood and drugs into his vessels and heart, and rhythmically pounded his chest. Nurses dispensed drugs from the ‘crash’ cart while other medical personnel assisted or merely observed the ‘arrest.’ In a few minutes the man’s heart began to beat on its own. Seeing this, the individuals who had been working so desperately a few minutes before to save a life stopped their efforts, made a few jokes in relief, and gradually filed out of the room. Through technological ‘miracles,’ another patient had been successfully brought back from the world of the dead.

In the next room a 7%year-old woman with pancreatic cancer lay dying. She, her family, and her physician had jointly made the decision that because of her age and severity of sickness, death should come peacefully and naturally. Thus her physician had written a do-not-resuscitate order in her hospital chart-if the woman had a cardiac or respiratory arrest, there would be no ‘code’-no life-sustaining equipment, no monitors, no frenzied activiq swirling around her as hospital staff attempted to prevent her death. Instead, she would be allowed to die quietly, when her body could no longer perform its vital functions on its own.

These scenarios reflect the developments in cardiopulmonary resuscitation (CPR) that have occurred in American hospitals since external closed-chest cardiac massage was introduced 30 years ago as a means of reviving patients whose heartbeat or breath- ing failed following surgery [I]. Rapid advances in CPR techniques soon offered a wide array of life-sustaining equipment and procedures for full pharmacologic and respiratory intervention in the threat of imminent death. Seen as a dramatic and lifesaving intervention, CPR came to be performed routinely on almost any patient who experienced a cardiac arrest in a hospital regardless of underlying condition, prognosis or age [2]. In the past decade, however, research has demonstrated the problems with widespread use of CPR: relatively few hospitalized patients survive cardiopulmonary arrest (3-51; the survival of certain subpopulations is virtually zero (6-131; the morbidity associated with CPR is high and the cost of subsequent intensive life support is substantial [2,3]; and CPR can cause unnecessary suffering in its prolongation of dying [4, 14-191.

Recognizing that CPR was inadvisable for some patients, many hospitals have now adopted policies that allow the use of a do-not-resuscitate (DNR) order when a patient’s death is imminent, when further treatment is considered futile, or when CPR, if successful, would only prolong the process of dying [6, 20-241. These guidelines require documentation of DNR decisions in the clinical record by the attending physician and consultation with the patient or patient’s family before the order is written [6, 19, 20, 23-261. These policies also assume that CPR will be performed automatically unless it has been explicitly countermanded by a DNR order in the record, and that the resuscitation effort will include advanced

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886 J~SSIC.A H. MLLLER

cardiac life support, including electrical defibrillation, administration of drugs, and mechanical ventilation. if these interventions are necessary to restore effective circulation and respiration.

Despite the establishment of these guidelines, problems with their application still remain (27-301. This paper addresses a problematic aspect of these guidelines from the perspective of resident physicians training in internal medicine: since the guidelines specify that a patient should be resuscitated if agreement on a DNR order cannot be reached, these physicians sometimes are obligated to provide treatment they consider futile. Although infrequent, this occurs in those circumstances of disagreement in which there are conflicting notions of appropriate patient care, and the patient, family, or senior physician do not share the residents’ conviction that a DNR order is appropriate for a patient because the patient is near death or the intervention of CPR would only increase the patient’s suffering. From the perspective of the residents, these situations of disagreement can create moral and practical dilemmas which have consequences for their daily work with

patients. It is the purpose of this paper to demonstrate

how medical resident physicians sometimes use an alternative or interim measure for dealing with this problematic aspect of their work-the negotiation of an intermediate ‘code’ effort which falls somewhere between full CPR and a DNR order. These practices offer a partial or abbreviated resuscitation attempt in which either CPR is initiated but stopped after a short while, only some interventions are carried out, such as the administration of drugs but not CPR or mechanical ventilation, or a code is intentionally conducted too slowly for resuscitation to occur. Limited codes have been criticized in the medical literature for being dishonest and deliberately inadequate attempts at resuscitation, for avoiding discussions of treatment futility and death, for causing confusion among medical staff, and for placing nurses and physicians in legal jeopardy [3, 14, 19, 27. 28, 31-341. There has been little attempt, however, to discuss the cultural meaning and circumstances of limited codes within the context of resident physician work in hospitals. This paper does not attempt to refute the criticisms that have been made of limited codes, but rather to illuminate the conditions under which they occur, and to demonstrate how they have emerged as an unofficial, negotiated response to what the residents perceive to be difficult and unworkable circumstances.

This analysis is based on the premise that health care workers and trainees often negotiate strategies for dealing with problematic aspects of their work or training. Strauss and his colleagues [35, 361, have suggested that it is often by negotiation (e.g. bargain- ing, compromising, brokering, etc.) among hospital staff, rather than by set convention, that agreements are reached about what is to be done daily and by

whom. These situation-specific agreements are made under conditions where rules and procedures are not extensive or intensive enough to cover the fluid and ambiguous nature of hospital work. Observers of professional training have also examined negotiating processes that take place during training. In their study of medical education, Becker and his associates

[37] have noted that medical students, when faced with overwhelming academic demands, attempt to negotiate manageable levels of effort and to establish appropriate directions for their efforts. Similarly, observers of nursing education suggest that students actively participate in the process of negotiating demands of training by assessing the demands of faculty and institutions and working out certain strategies both personally and collectively [38]. Commentators on residency training also have paid careful attention to the strategies trainees develop to cope with the difficult aspects of their residency training and medical practice [39-421.

The discussion which follows addresses a particular

form of negotiation in one area of clinical practice- decisions about life-sustaining treatment. After an examination of the cultural meanings of resuscitation and its withholding for residents and their work, the features of limited codes and the circumstances in which limited codes are negotiated are discussed. Consideration of limited codes is then situated in their cultural context, with particular focus on the dilemma that house officers find themselves in and its moral and practical consequences for their work with terminally ill patients. The final sections of this paper are devoted to a discussion of the role that limited codes play within the context of resident work and the means by which they form one cultural response to the complex and often ambiguous situations that arise within contemporary medical practice.

.\IETHODS

The material for this discussion is drawn from a larger study which examined the care of dying patients by internal medicine resident physicians [43]. The objectives of the study were: (I) to portray the day-to-day practices of medical residents (also known as house staff physicians or house officers) and the ways in which their tasks and activities change as patients move from the status of living to the status of dead; (2) to describe the attitudes, values, and beliefs of medical residents about their work with a patient population which is near death; (3) to identify the criteria by which persons are assigned to the category of the dying; and (4) to examine social and cultural factors which influence the process of decision-making by medical residents in the management of dying patients. This research was conducted over a period of 18 months in 1982-1984 on the medical wards of 3 primary teaching hospitals affiliated with an urban medical school, including a

The negotiation of limited codes by medical residents 887

tertiary care center, a public county hospital, and a Veterans Administration hospital.

Since the care of patients by resident physicians in teaching hospitals is organized according to house staff ‘teams’ (typically comprised of 1 or 2 first year residents, a senior resident, an attending physician, and 1 or 2 medical students), 13 medical house staff teams at the 3 hospitals were selected for study. The investigator became an unofficial member of the house staff teams during the research period in order to observe medical residents in their natural context as they rotated in month-long blocks of time through the medical services of the 3 teaching hospitals. The senior resident on each team was asked to identify the patients who were highly likely to die within the next few months. A total of 55 patients were so identified. The investigator followed the care of these patients during the course of their hospitalization until their eventual death or discharge from the hospital.

To elicit individuals’ perceptions of the management of dying patients as well as behavioral data, the research methods employed for this study combined an intensive observation with semi-structured and unstructured interviews with study participants. Observations were conducted at various times of the day and night and at different observation posts in the hospitals to insure adequate selective sampling of the dimensions of time, space, people, and events. The researcher followed teams while they made their daily rounds, watched interactions with patients and colleagues, attended conferences with house officers, shadowed individual team members as they carried out the tasks of patient care, and spent weekends and ‘on call’ nights in the hospital. Particular attention was paid to the set of activities, interactions, discussions, and comments concerning those individuals who were classified as dying.

During the data collection period both unstructured and semi-structured interviews were conducted. Unstructured interviews with house officers, which occurred informally as time allowed, were left open- ended to allow informants the opportunity to express the details of their experience as they perceived it. One hundred semi-structured interviews, which were audiotaped and transcribed, were also conducted with members of the house staff teams to ascertain their experiences and perceptions of dying patients. These included 83 interviews with residents, 7 interviews with attending physicians, 5 interviews with medical students, and 5 interviews with chief medical residents. These interviews were conducted with an interview guide, although study participants were encouraged to respond at length to questions and to discuss events or ideas that were of importance to them.

During the course of these interviews residents were asked, among other things, about the code status of their patients, including questions about the meanings of resuscitation and its withholding to them, the decision-making process, the parties

involved in the decision, conflicts over the decision, the type of care being given patients, temporary code decisions, if any, and the final code decision. As the research progressed, it became apparent that under certain conditions intermediate steps between full CPR and DNR were sometimes considered by the residents. Sixteen instances were observed or were reported on by residents where some type of intermediate code was either discussed as a contingency plan-something they would do if a patient suffered cardiac arrest-or was actually undertaken as a response to a patient’s arrest. In four cases discussions among members of house staff teams of the pros and cons of limited codes were observed directly. In the rest of the cases the planned or actual use of limited codes was reported in interviews. ‘Intermediate’ or ‘limited’ code thus became a core category for analysis.

Collection and analysis of data followed a grounded theory approach [44-461. Qualitative content analysis [47] was conducted by identifying the major themes that emerged in the fieldnotes and interview transcripts and by developing increasingly refined categories for analysis of content and meaning. The following discussion uses quotations from resident interviews and fieldnotes from the investigator’s daily journal to illustrate the recurrent themes that emerged from the analysis.

RESUSCITATION IN THE CONTEXT OF RESIDENT WORK

The world of the residents

Upon graduation from medical school, physicians intending to specialize in internal medicine join a 3-year internal medicine residency training program affiliated with teaching hospitals. The ‘work’ of the residents during their training consists of numerous multifaceted tasks. For the first time, they assume major responsibility for the day-to-day management of patients. These patients, who are either admitted to the hospital by their private physicians or through the medical center’s emergency rooms and clinics, represent all socioeconomic statuses and medical conditions, thereby giving the residents exposure to a wide and varied patient population. Although resident physicians in teaching hospitals are not solely responsible for patient care since they are supervised by attending physicians and they must work with the physicians of private patients, the degree to which more senior physicians become involved in the day-to-day management of patients is highly variable. As a result, medical residents participate in many kinds of decisions concerning patient care, including decisions about the withholding or withdrawing of life-sustaining treatment.

While carrying out patient care activities, the residents also are learning the skills, knowledge and culture of internal medicine. Through such occupational

888 JESSICA H. MULLER

rituals as attending rounds, morning report, grand rounds and conferences, the physicians learn and dramatize a conscience collectice-the ways of think- ing, feeling and seeing common to this group of physicians [48]. In the process, they are initiated into the systems of meaning that are most highly valued in the world of the university teaching hospital. These include forms of knowledge and activity for which internal medicine residents will be held accountable and for which they are most likely to be rewarded- sophisticated knowledge of pathophysiology, technical competence in gathering and interpreting data and arriving at a diagnosis, the acquisition of medical knowledge, the ability to meet a diagnostic challenge, and skilful physiological and technical management

of disease [43,49]. At the same time that residents are acquiring and

practicing the skills, knowledge, and shared under- standings of internal medicine, they must also learn how to be effective house officers in order to successfully complete their training. Not only does this mean acquiring culturally appropriate behavior, such as presenting information in the acceptable manner and learning the moral rules that shape behavior in this environment, but it also means learning how to negotiate the demands, pressures and expectations of residency training [40, 41, 501. First year residents, or interns, in particular face long hours of the extremely demanding work required by the day-to-day tasks of patient care-writing in patients’ medical records, fill- ing out forms, ordering tests, performing procedures, discussing patients with other staff, attending conferences, etc. To perform effectively as house officers in this world of grueling schedules and continual exhaustion, residents must have ways of managing the demands of their work to ensure that tasks are accomplished, administrative details are taken care of, chartwork is done, and other staff are informed so that the work of taking care of patients proceeds as smoothly as possible.

These elements of residency training were brought into relief in the arena of clinical practice which involves making decisions about offering, withholding or withdrawing life-sustaining treatment for seriously ill patients, in particular decisions concerning cardiopulmonary resuscitation. Because the option of not resuscitating patients now exists, - residents on the medicine wards participated daily in decisions about whether or not to resuscitate their hospitalized patients-decisions which had direct impact on how patients lived, how long they lived, when they died, and in what way they died. For many residents the nature of these life and death decisions raised questions about their responsibility to their patients, the values inherent in medical practice, and how they, as physicians, should spend their time caring for patients. These questions became especially pertinent with respect to CPR because of the dual and potentially contradictory nature of CPR as a medical intervention.

Offering resuscitation

As a medical intervention, resuscitation dramatic- ally symbolizes a means by which the dead can be ‘brought back’ to life. Since CPR takes place at the point when pulse and respiration have ceased- when death, as it is popularly conceived, has already occurred-this intervention represents the one possibility to restore, to renew, or to revitalize life; to not attempt it signifies certain death [16, 17). For physicians and laypersons alike, CPR has become a symbol of the ability of medical technology to extend clinicians’ power over health and illness. Because CPR has provided this capacity to promote and sustain life, clinicians take it as their moral obligation to attempt resuscitation if a patient experiences cardiopulmonary arrest unless compelling reasons dictate otherwise. As the following resident suggests, most patients, unless they are expected to die

imminently or their quality of life is poor, ‘deserve’ resuscitation:

If you think there’s a realistic expectation that he’s got months to years of fairly decent quality of life, that’s an awfully big presumption to make, to make that person a no code. A difficult decision, to say when and where he crosses that line, where, if he passed away suddenly or he died suddenly, we wouldn’t resuscitate him. For me, he was fairly clear on the other side of that line. He was someone who deserved resuscitation. (Second Year Resident.)

The question of ‘code status’ normally did not arise in the daily discussions among the house staff if there was unspoken consensus that a particular patient deserved resuscitation. It was assumed by the physicians that if the patient suffered an arrest he or she would receive basic CPR as well as advanced cardiac life support, including, if necessary, admit- tance to the intensive care unit, mechanical ventilation, electrical defibrillation, administration of drugs, a temporary pacemaker, or even open-chest cardiac

massage. At the same time, however, the house officers were

acutely aware that while CPR offered the possibility of reviving a patient, it was also an invasive and aggressive procedure which had the potential to inflict enormous harm and suffering. The severe neurological and brain damage that could result from a resuscitation attempt, even if it were successful in restarting a heart beat, was often a fate worse than death from the residents’ perspective. Just as horrify- ing in their view, and even more likely, was an extended stay in the intensive care unit, where the patient was subjected to multiple invasive, painful, and costly procedures until death was finally unavoidable.

Thus, the resuscitation decisions the residents were forced to make often put in conflict two of medicine’s fundamental values-preserving life and preventing suffering-and raised perplexing questions for them: when is CPR unwarranted? How unlikely must reviving the patient be to make a DNR order appropriate? What role should possible functional outcomes of CPR play in their decisions? [5, 61.


Withholding resuscitation

If residents concluded that a resuscitation effort would be futile because there was little possibility that it would successfully reestablish cardiopulmonary function or postpone death [30], they brought up the possibility of a do-not-resuscitate order in discussions with their attending physician. They also typically raised the issue if a patient had a terrible prognosis because of irreversible disease or they believed the patient would incur severe and unnecessary misery by the application of extraordinary therapeutic measures. Residents made predictions in these cases about what the patient’s quality of life would be like and the possibility for meaningful existence, if he or she survived resuscitation.

When you feel that the patient has no happiness in life to look forward to, that there’s nothing we can do to improve the patient’s quality of life, and when the patient is on the verge of going into cardiorespiratory arrest in a situation where all of our efforts medically have failed, so in that situation I would feel comfortable in requesting the attending to write a no code order, so that the effort would not be made to resuscitate this patient for whom the future was bleak. (Intern.)

If the attending physician agreed that a DNR order was appropriate, it became the responsibility of the resident in charge of the patient’s care to discuss the possibility of a DNR order with the patient if he or she were competent, or with a family member if the patient were incompetent, in accordance with the DNR guidelines. If all the actors involved in the patient’s care agreed with this decision, the resident asked the attending physician to write the order in the medical record. The care of the patient was then managed accordingly until the patient died or further discussion of the DNR order was required by additional changes in the patient’s status.

The DNR order and resident work

Although hospital guidelines stipulate that a DNR order should refer only to the withholding of CPR and should not alter other forms of care [6,25], in the reality of clinical practice there were varying interpretations of this policy. In many cases aggressive medical interventions were either continued or initiated after a DNR order had been written; in other situations, however, particularly those of patients with terminal diseases who had lingering illness trajectories, the do-not-resuscitate order sym- bolized a shift in the residents’ view of the patient’s status. It became an acknowledgement that the patient was beyond any hope of recovery and that there was nothing further medically that they. as physicians could do. Their medical therapeutics had failed and the patient was dying [51]. In these cases, the DNR designation made formal recognition of a predictable and hopefully uneventful passing.

Defining a patient as ‘no code’ in these situations became the basis for the residents’ ensuing behavior toward that patient by serving to direct the type and

extent of care they gave to a patient. For these patients the DNR order indicated a general shifting of treatment goals from aggressive and therapeutic care to palliative or supportive care aimed at symptom control and comfort. With a DNR order in place, the doctors did not have to explore every diagnostic puzzle or pursue the latest therapeutic intervention for their patient; they could rein in their technology, and cease the struggle against death because death, in their view, was inevitable.

This redefinition of their tasks and obligations gave the residents clues as to what to expect in terms of their daily routines: what kind of work they would have, how much they would have to do, and for how long. Having ‘typified expectations’ [52, 53]--knowing what to expect from predictable situations-was critical for how the interns in particular, who had major responsibilities for the daily management of patients, organized the multitude of tasks they needed to carry out during the course of a day or night. Knowing more or less what to expect from their work rendered their work more predictable, orderly and routine. The importance of such expectations with respect to dying patients was manifest when interns leaving for the day ‘signed out’ their patients to the intern on call:

If someone’s going to die, I guess we feel that it’s always important to convey that to the other team. If a person’s going to die. there are a lot of things that are going to come up.. . If the person is a code, for sure [the intern] is going to be paged very often and is gonna have to do a lot of work that night. If the patient is a ‘no code,’ then he’s going to be paged later on, and either be told that a patient is going downhill and he needs to know not to intervene, or he will be called and told that the pa&t has expired and he’s going to have to pronounce the patient dead, fill out all the forms, and everything like that.. So the key of signing out is to let the person cross-covering know of any potentially dangerous patients.. so they know where the trouble spots are in the hospital. (Intern.)

As this intern points out, the residents want to know which patients are ‘potentially dangerous’defined in their world view as those who may require a lot of work-so they can better predict the amount and type of work that faces them. A dying patient who is a ‘no code’ may require considerable work, but the DNR order signifies to the residents what tasks they will not do. If a dying patient is a ‘code,’ however, - residents were aware that they might well have to spend an enormous amount of time and energy with that patient in the attempt to employ whatever was available in their therapeutic armamentarium to reverse death.

Let’s say there’s a terminally ill patient that you think should be a no code, and they are not, and you know that every time they spike a temperature, you’re going to have to work it up. And you full well know that their temperature may be from their cancer, or something else, and yet you’re obligated to work it up, and then it just becomes an exercise. You feel like your time would be much better spent with another patient that’s more viable-you know that you’ll just be exhausted working on them. There’s not much that


you’re learning from them. So they’re taxing you, and you’re not learning that much. (Intern.)

This intern suggests how not having a DNR order in the chart of a patient on a downward spiral towards death can play havoc with the work order of the residents [54]-that organization of activity surrounding the care of critically ill patients which is required to ensure that whatever tasks are necessary are accomplished and in a timely fashion. Moreover, being forced to care aggressively for terminally ill patients who would soon be dead took, from the residents’ perspective, time and energy away from their central educational tasks. As noted earlier, these young physicians in internal medicine were being trained in how to conduct extensive and intricate ‘work-ups’ to arrive at diagnosis. to select and employ highly technologically and scientifically sophisticated interventions, and to competently master numerous technical skills and procedures. Once they had mastered basic patient care skills, many residents believed they learned little from the routine, the mundane, or the untreatable. They continued to learn, however, from the ‘interesting case’- someone with an unusual or difficult condition which expanded or challenged their diagnostic acumen,

medical knowledge, or management skills. Dying patients, unless they were dying from a rare disease or presented unusual management demands, rarely offered to the residents the challenges of diagnostic puzzles or therapeutic conquests [43, 511. This led to the frustration commonly experienced by residents working with dying patients that is reflected in the final comment of the intern quoted above, “So they’re taxing you, and you’re not learning that much” [55].

NEGOTIATING SLOW CODES

Despite hospital guidelines which required CPR

unless a DNR order had been specifically noted in the medical record, observations and interviews disclosed that resuscitation efforts falling somewhere between a full code and a no code were occasionally planned or conducted. These intermediate codes were known by the house staff as ‘partial,’ ‘limited,’ ‘show,’ ‘soft,’ ‘slow,’ or ‘light blue’ codes-each term conveying information about the type and extent of response that would be made in the event a patient suffered cardiopulmonary arrest. A partial, limited, or soft code referred to situations where drugs might be given without chest compressions, or where cardiopulmonary resuscitation might be initiated but drugs would not be administered or intubation performed. A show code referred to the practice carried out by health care personnel of initiating resuscitation but stopping the procedures after a few tries or a pre- determined period of time, a largelrjymbolic gesture intended to reassure the patient’s family (or themselves) that ‘everything was done.’ In a slow or light blue code, the physician might ‘go lightly’ or ‘walk, not run’ if the patient had an arrest.

These intermediate codes efforts tended to take the form of an informal arrangement which was negotiated verbally between residents or between a resident and a nurse, often at night, where they agreed beforehand what they would do, and how much they would do, in case a patient had a cardiac arrest. Sometimes, although not always, the attending physician was consulted, and the decision to make a patient a limited code was negotiated between the house officers and attending physician. Occasionally the medical reasons for selecting among the various techniques of resuscitation were noted in the patient’s record, although often the decisions were not formalized in writing.

Intermediate codes are deviations from established protocol and regulations; therefore, they represent the masked, informal aspects of clinical practice and were not easily observable, publicly acknowledged occurrences. Only 16 instances (561 were observed or were reported on by residents. Because the practice of intermediate codes ran counter to hospital regula-

tions, the residents only considered or engaged in this practice in those limited circumstances when the house staff were convinced that a DNR order was appropriate for a terminally ill patient. They took this view when they believed the patient was near death and would not benefit from further treatment; when they feared the patient would not respond to basic CPR and would require longterm mechanical ventilation; or when they were concerned that CPR, even if it were successful in restarting heart or lung beat, would cause irreversible brain damage or significant deterioration in a patient’s quality of life.

Occasionally, however, family members or other physicians involved in the care of the patient had differing definitions of the patient’s situation and often conflicting notions of the appropriate goals for patient care. If discussion faltered or attempts to reach consensus failed, the frustrated or angry residents sometimes claimed they would consider the use of a limited code to avoid the possibility of a futile resuscitation attempt. This response tended to appear under two conditions: when the family of a terminally ill patient disagreed with the medical consensus that the patient would die in a few days no matter what treatment was given, and when the house staff felt their attending physician or their patient’s private physician was not responsive to the clinical realities of a patient’s situation.

Disagreement with families

Guidelines about DNR decisions stipulate that such decisions should be made by the health care team in conjunction with the patient if he or she is capable of understanding the risks and alternatives, or with the family or surrogate if the patient is not competent to make these decisions [6, 19, 20, 23-261. As a result. even though there are no legal grounds at present to require assent for DNR orders from family unless a family member has been appointed


legal guardian [57], the residents were fearful of poss- arrangement until the expected death occurred or ible legal action if the family of a patient disagreed until a DNR order could be obtained. In making with their judgment regarding a DNR decision. these arrangements, the senior resident negotiated Consequently, in situations of disagreement a DNR with the cross-covering team about how to limit the order was rarely placed in the patient’s medical type and duration of their resuscitation efforts if the record, in accordance with the guidelines which posit man had cardiac arrest: that all parties must be in agreement.

These situations of disagreement tended to arise We made the team covering the patient aware of his

when family members of mentally incompetent preferences and that a long code was not indicated. . . he is

patients insisted on aggressive care, including CPR in not a young 35-year-old where you are going to spend an hour-and-a-half on a code. You’re going to give basic

the event of cardiac arrest, despite the physicians’ resuscitation, and if it works, it works, and if it doesn’t,

assessment that the patient would die in a few days you’re not going to put him in the [intensive care] unit. . . .

regardless of further treatment. From the residents’ SO he was one of those who probably fit into the category

perspective, insistence on the part of the patient or of a slow code or whatever it means. (Resident.)

family that ‘everything be done,’ including CPR, In another situation where a family continued stemmed from their refusal to accept the physicians’ to demand aggressive care in the face of futility, definition of the patient as terminal, from unrealistic residents planned the use of a ‘show code’ to reassure expectations about the prospects for a patient’s the family that every attempt had been made to recovery, from undue optimism about the physicians’ resuscitate a dying patient. ability to provide beneficial treatment, or from lack of understanding about the meaning of a DNR order. A senior resident reflected on the lack of communication between health care providers and family members in a description of an elderly man dying from pancreatic carcinoma who had continued to insist on maximum treatment before he became unre- sponsive:

We talked to his family because we thought he was being unrealistic about even wanting us to intubate him when his life expectancy, in looking at it, was less than a month. He was the one guy we could probably predict. . . . But talking to the family yielded nothing because they said whatever he wants done, we want done. So he was a full code until the day of the death and the day of his death his daughter called us. She had come to see him and he was getting moribund, he was not doing well.. . She said, ‘What does no code mean, does no code mean you stop it?’ I think really it was a lack of communication. I don’t know what she thought a no code meant but I think she thought. . [it was] withdraw support, which was not what we were gonna do. (Senior Resident.)

There is another example of a Chinese gentleman with hepatoma widely spread-learly an aggressive tumor. No effective therapy, dying, he was demented as well, and the family was struggling to keep him alive. Not allowing us to make him a no code because the son was getting married soon and if he died before the son got married they would have to postpone their wedding a year, that was a cultural condition. And clearly this was a man you would not want to resuscitate. He’s dying a horrible death.. . [So we told the cross-covering team] in discussions that ‘Yes, he is a code, please don’t be aggressive. If he codes, make a few efforts. If it was clear he wasn’t easily resuscitable, then stop.’ (Intern.)

These examples suggest that the planning for a limited code often took place as an informal and verbal arrangement between members of two house staff teams, where the participants negotiated beforehand what a code effort would consist of if the patient suffered a cardiac arrest. Such arrangements were used particularly in cross-covering, when interns going off duty in the evening ‘signed out’ their patients to the ‘on call’ team who would then be

In such situations, the residents worked hard to responsible for the patients until the regular team convince the family that, given the patient’s condi- came back on duty, and who, in conjunction with tion, CPR would most probably be futile because it other medical personnel, would respond if a patient would not successfully re-establish cardiopulmonary experienced cardiopulmonary arrest. The residents function or would cause serious brain damage. If who had been taking care of the patient felt it was their attempts at persuading others of their definition important to clarify for the cross-covering team what of the situation failed, however, the physicians were they would do if the patient had an arrest, particu- confronted with the prospect of having to provide a larly if there was any ambiguity about the code status medical intervention they not only thought was futile of the patient. If they were present at the time their but might very well cause enormous suffering for the patient suffered an arrest, they could rely on their patient. knowledge of the patient and his or her prognosis

It was under conditions like these that residents to decide which heroic measures to employ in the reported they might use a limited code. In 7 out of attempt to prolong his or her life. The cross-covering 16 instances of limited code use, residents stated team, however, did not have the benefit of the they had planned or engaged in this strategy because in-depth knowledge of the patient which comes from they believed that the futility of further aggressive prior contacts and conversations, and therefore treatment justified overriding the family’s wishes. For sometimes did not understand the subtleties of the example, in the case described above of the patient patient’s care unless they had been specifically with terminal pancreatic cancer whose death was instructed by the patient’s doctors. The potentially imminent, a slow code was planned as an interim disastrous consequences for patients of a breakdown


in communication between a patient’s doctors and the cross-covering team are suggested in the comments of this intern in his explanation of how he signed out a patient who did not want to be intubated in the event of a respiratory arrest:

I mean, that would have been the worst possible situation, if I’d come in the next morning and found out that, you know, he’d been intubated without the intern or the resident really knowing what the situation was. So I tried to, as best I could, relay the current status of the code. (Intern.)

In this case the intern noted on the index card he gave to the cross-covering intern, which contained information about his patients’ diagnoses, medications, and management plans, that the patient in question was a ‘limited code.. no unit, no intubation, but everything else.’

On occasion, the residents negotiated with patients what the particular shape of a code effort might be. This tended to happen in those situations where there was disagreement among family members about the type and extent of treatment to give a patient. For example, a man newly diagnosed with metastatic lung cancer did not want heroic measures to save his life but his wife was adamant that everything that possibly could be done should be done, including intubation in the event of an arrest. Eventually the intern and patient came to the agreement that, out of respect for the wife’s wishes, a DNR order would not be written in the chart but the man would not be intubated if he suffered a respiratory arrest. In

describing the situation the intern commented:

After we got to know each other better and I felt more comfortable talking to Mr S. about it, you know, it really came out that he didn’t want to be aggressively treated-or helped if it really wasn’t going to prolong his life. And towards the end of his hospitalization we actually came to a sort of agreement between him and myself that if something were to happen that we would try to use our best judgment not to really prolong him.. I signed him out as a full code every night but I always told the intern on call that this was a gentleman with terminal cancer and that people should use their common sense about how aggressive to be.. . I’d always say that the patient does not want to be intubated, his wife does want him to be intubated, and they’d have to use their best judgment. (Intern.)

Disagreement with senior physicians

House staff also considered the use of limited codes under the following conditions: when an attending physician was not available to write a DNR order; when attendings and residents had differing interpretations of a patient’s status and future; when an attending physician feared adverse medical or legal consequences of a DNR order; or when a. patient’s private physician had not discussed the possibility of a DNR order with a patient or family member.

Unacailability of attending physician. In two instances residents reported planning slow codes for newly admitted patients who were clearly near death because their attending physicians were not available to write the DNR order. For example, when an 87-

year-old man dying from metastatic prostate cancer was admitted to the hospital for terminal care, a DNR order could not be entered in the patient’s record at the time of admission because the attending physician was not in the hospital at the time. The second year resident in charge of the case explained what would have happened if the patient’s heart had

stopped beating:

The nurses would have called [the code] because that’s what they’re bound to do, and people would have come running, and I would have been there. I would have told the [code resident] that nothing should happen.. But if I was at dinner, if I wasn’t the first one there, then he would have been intubated. It would have been chest compressions, broken ribs, cardiac laceration, it would have been abomin- able. So anyway, I talked with the nurses, because they’re the ones who call the code, and said, ‘The attending is coming by, and meantime, don’t call [the code]. Call me first.’ (Second Year Resident.)

This comment illustrates two features of limited codes, First, it demonstrates how they were sometimes planned as a contingency measure until a DNR order could be written in the chart. In these cases there was the expectation that this was a temporary solution to a temporary problem which would be taken care of as soon as the proper authority could write an order. Secondly, it exemplifies the ways in which residents sometimes negotiated an intermediate code with nurses. Even though the nursing profession has objected to the fact that nurses are being asked to participate in an act that is legally ambiguous

[SS, 591 nurses sometimes played an important role in slow code decisions because they were the ones who most often found a patient in cardiorespiratory arrest and thus were responsible for ‘calling’ the code. Therefore, if the house staff did not want a patient to receive full resuscitation, it was necessary for them to communicate with nurses in advance exactly what they desired. In these situations the residents instructed nurses to page them personally if their patient arrested, rather than alert the CPR team over the hospital’s public address system. In this manner the resident could assume responsibility for conduct- ing a limited code. On the basis of his or her clinical judgment and knowledge of the patient, the resident would give at the patient’s bedside the instruction not to institute resuscitation or to stop after a few basic maneuvers.

DifJering interpretations of status. In five instances differing definitions of a patient’s status and treatment emerged among the house officers and their attending physicians, leading to differing notions of the advisability of a DNR order and the subsequent consideration of a limited code. A central point of disagreement concerned what weight to give the possible functional outcomes from CPR when there was the possibility of further medical treatment. This is illustrated in the case of a patient, suffering from squamous cell carcinoma of the hypopharynx which had metastasized to the spinal cord, who was required to wear a metal support screwed into his


skull to hold his neck rigid. Faced with the possibility of a ‘wrench code’ (so named for the wrench taped to the patient’s bed which would be necessary to loosen screws if he experienced cardiac arrest), the senior resident on the house staff team pushed for a DNR order because a resuscitation effort would not only be extremely difficult to carry out but would also likely result in serious brain damage even if it were successful. However, because certain treatment options were still available for the man’s disease, the attending physician initially was unwilling to consider a DNR order despite the probable consequences of a CPR attempt. As this fieldnote suggests, the resident was disturbed by the attending’s apparent reluctance to make a decision:

The resident said that the attending has been reluctant to write a no code order on Mr. B. because head and neck cancer is reversible. The resident added, ‘(The attending] is being passive aggressive about this and it really bothers me.’ He explained that the attending says he agrees with the resident in attending rounds but doesn’t do anything about it because he feels uncomfortable with it. It is the resident’s position that a no code order should be written and the sooner the better-no ventilator, no mechanical CPR. He said he would be willing to do a ‘chemical code’-bring his volume up if his blood pressure drops, give him lidocaine. (Fieldnote.)

Eventually, the attending physician and the resident jointly negotiated a mutually acceptable definition of the patient’s situation and treatment-he would be a limited ‘chemical’ code. In case of arrest, he would receive medication to maintain his blood pressure but would not undergo basic CPR (chest massage and mouth-to-mouth resuscitation) or mechanical ventilation. According to plan, the resident directed the nurses to call him if the patient’s status deteriorated so he, rather than the resident in charge of codes, would assume responsibility for the progress and type of the code. The attending, aware that he was not strictly following regulations, remarked in a team meeting after writing the order that his note in the patient’s medical record would undoubtedly cause some controversy since it ‘deviated a few degrees’ from hospital policy.

Another point of disagreement regarding a patient’s status concerned whether or not an attending physician would write a DNR order when the etiology of the patient’s condition was unclear. In the following example an attending felt unable to write a DNR order despite the severity of a patient’s condition because he did not understand why the man was presenting with that particular set of symptoms:

A patient. came in with hepatic encephalopathy, and had ascites, was septic, and had no corneals, fixed and dilated, and was nor made a no code. Was on dopamine and Levophed for the past 24 hours. Blood pressure of 30 and 40. And no one had thought to make him a no-code.. . I was cross-covering, and called [the attending] at 1 I:30 p.m. and I said, ‘Why is this man not a no-code?He’s fixed-and dilated and he’s had no blood nressure for the last 24 hours.’ And he goes, ‘Well, because-ethically I don’t understand why this man is presenting like this.. . what caused this? I

can’t make him a no code, because ethically I don’t understand what’s going on.’ But I said, ‘Yeah, but he’s fixed and dilated; he’s dead already, why prolong this? And he said, ‘Well, I’ve been burned before and I can’t make him a no code.’ So I said, ‘Well, how am I going to deal with this tonight? (Second Year Resident.)

As this resident suggests, discussions of the intrica- cies of code decisions were frequently difficult in cross- covering or emergency situations because residents often did not have the time or prior knowledge of a particular patient to pursue the reasons for different courses of action with the attending. In situations where a patient was near death, an attending’s unwillingness to write a DNR order was problematic for cross-covering residents who were left feeling uncertain how to treat their patients if cardiopulmonary arrest occurred. In the case described above, the resident ended up negotiating with the nurses how to treat the patient when his heart went into an abnormal rhythm during the night.

Fear of medico-legal consequences of DNR. Fear of adverse legal or medical consequences was another reason that house officers felt attending physicians were sometimes reluctant to write a DNR order when a patient was near death. Legally responsible for patients, attending physicians expressed concern about the possible legal ramifications of DNR orders and their own liability [60]. Some physicians were also afraid that a DNR order would result in inadequate care for their patients. It was not uncommon to hear on the medicine wards such comments as: “Once you get a no code label in the chart, it’s hard to get anything done.” Even though research has indicated that such an order does not appear to result in poor medical or nursing care for patients in hospitals [61-631, some attending physicians were reluctant to write an order not to resuscitate to avoid any possibility of inadequate care. In one reported case, a resident felt obligated to plan a limited code as a means of circumventing a particular attending physician who might require resuscitation out of fear of being held liable for malpractice.

One attending of mine that I had last year would not sign a no code order. You’d ask him specifically ‘you mean, if this patient goes into cardiorespiratory arrest, do you feel he should be resuscitated?.’ He’d say, ‘No, but I will not write a no code order. I will not take personal responsibility to do that.‘. [So] we would sign him out as a non-technical no code. We would say [to the nurses], ‘This patient-you know, he doesn’t want him to be resuscitated, but our attending won’t sign the order.’ The nurses will be required to call the code. ‘When you get there, just stop it right away.’ It’s not optimal. (Intern.)

No discussion about DNR. Finally, residents occasionally felt forced into carrying out some form of a limited or show code when the private physician of a dying patient had not discussed the possibility of a DNR order with the patient or his or her family. This occurred particularly in emergency rooms or cross-covering situations where the residents did not know the patients and therefore had not been able

a94 JESSICA H. MVLLER

to initiate code discussions with the patients or their families themselves. In the case described by the resident below, the patient’s own physician appar- ently had avoided discussion of the issue of death and the limitation or withdrawal of medical treatment with the patient or family. Consequently, the possibility of not resuscitating the patient had never been raised, and the accompanying order never entered in

the patient’s medical record. For the resident assigned

to the dying patient, this left no alternative but to

initiate a code, causing anger and frustration on the

part of the house staff:

There was a patient who came in here last week when I was on by myself, and I got this call from one of the gynecol- ogists, it was her patient. The woman had end-stage, widely metastatic ovarian carcinoma. so she was calling us to let us know that this patient was gonna come rolling in. And so I said to her, ‘What do you want me to do about it now? Do you want us to code this patient, or what?’ And she said, ‘Well, no, don’t.’ And I said, ‘So you have an arrangement with the family? Do you have an understanding with the family that she won’t be coded?’ And she said no. And I said, ‘Well, thanks a lot!’ Because that doesn’t leave me any choice. And hung up on her. And then the patient came in and they brought her into the code room.. So we went through this half-hearted code. And about 15 or 20 min later, stopped. But it was really unnecessary. And it was revolting to me in a lot of ways.. I was incredibly angry at the physician, who should have long ago had that discussion with the family, and should have anticipated that the day would come when this would arise, and come to some agreement, and hadn’t, and had really dropped the ball. And because she dropped the ball, I was stuck, and we were collectively stuck in engaging in a very distasteful process to a woman who was effectively dead. (Second Year Resident.)

THE SOCIAL ROLE OF SLOW CODES

A resuscitation dilemma

As the statements of the residents quoted above suggest, the absence of a DNR order in the medical record of a patient who was near death or who would be seriously harmed by a CPR attempt created a dilemma for the house staff. As employees of hospitals and members of a residency training program they were required to follow the hospital policies which require that resuscitation be initiated for every cardiopulmonary arrest in the absence of a DNR order, and that such an order could be written only with patient or family consent. Yet these regulations did not adequately cover those situations encountered by the residents when there was serious disagreement among the parties involved in the care of the patient about the appropriateness of the DNR order.

In these situations the residents were backed into an ethical corner. In keeping with commonly ac- cepted ethical principles in medicine which suggest that the possibility of benefits offered by a medical intervention must outweigh its burdens for it to be justified [19, 25, 29, 641, the residents were reluctant to provide medical treatment that was, in their view, of no demonstrable benefit. They were aware that

offering a medical intervention such as CPR may represent the patient’s best interests if a patient has a good chance for reasonable survival with resuscitation, but it may not represent the patient’s best interests if that chance is slim. When the potential for benefit is virtually nonexistent, the iatrogenic harms of CPR take on added meaning, and become an even stronger violation of the physician’s moral imperative to ‘do no harm’ (65). The residents believed it would be a tragedy to resuscitate patients who almost certainly would not survive or would suffer extensive brain damage if they did survive, yet officially they were required to attempt resuscitation because a DNR order had not been placed in the patient’s record. As a result, patients would be resuscitated because hospital guidelines left no other choice.

Circumventing official policy

Negotiating intermediate codes, with nurses or other house staff, even though such practices trans- gressed hospital guidelines, became one strategy by which some residents, and occasionally attending physicians, informally coped with this dilemma. In those few circumstances where the residents were convinced that the futility or potential harm of further treatment justified overriding the families’ wishes or the statements of the attending or private physicians, the consideration of intermediate codes gave the residents a way of circumventing strict interpretation of hospital policies. It allowed them a means of restricting their therapeutic activity when they confronted the possibility of having to provide treatment they not only thought was futile but could also inflict significant harm on the patient.

In so doing, the use of intermediate codes allowed house officers to practice taking responsibility for their own actions in the face of conflicting interpretations of the situation. As described earlier, beginning physicians are taught from their earliest days on the wards the importance of taking responsibility for the medical care of their patients. One area of responsibility that house officers learn during the course of their training is to be able to defend their diagnostic and treatment decisions for their patients in the face of medical uncertainty or disagreement with other personnel. Exercising this responsibility in the care of critically ill patients can be particularly difficult for beginning clinicians because of the uncertain and problematic nature of care which so immediately involves questions of life or death. Treatment of patients who are highly likely to die is an area of clinical practice which is often complicated, painful, and fraught with uncertainty: clinicians are rarely sure when patients are going to die until death is imminent; decisions about whether and when to limit treatment often are not clear-cut and may be agonizing to make; and people involved in the care of the patient often have differing notions of the appropriate goals for patient care [14,43].


If residents felt strongly that a patient should not be resuscitated in the event of an arrest but a DNR order had not been placed in the patient’s chart, designating a patient as a limited code as part of the sign-out procedure became one way the residents tested in a limited setting their own notions about responsibility for a patient’s well-being. By not forcing what they perceived to be unwarranted aggressive treatment on certain patients, they could satisfy themselves that they acted in a morally jus- tifiable and appropriate way by having followed the ‘right,’ even if unofficial, procedures in the proper care of a patient. The importance of being able to assume this responsibility is conveyed in the following statement made by a cross-covering intern when justifying his limited code decision for a patient who was very near death but had not been made a ‘no

code.’

phe attending] just couldn’t bring himself to write the no-code order. That’s his opinion. But when I’m on the line, when I’m the physician there, I guess my opinion is worth something too. So I took it upon myself to do what I felt. But when things like that have come up, I’ve always called attendings to see heir side of the issue. And he talked to me for about an hour. Even though after an hour 1 had talked to him I still didn’t agree with what he told me. And so then at that point you have only yourself to fall back on. Then you do the way you feel, what you feel is right. (Second Year Resident.)

Negotiating effort

Consideration of limited codes also became a means by which residents attempted to negotiate the level and direction of their work with dying patients. As described earlier, the current system of graduate medical education subjected these house staff physicians, particularly interns, to an extremely heavy patient load and an endless number of tasks to carry out, which were often directed towards caring for patients who were terminally ill. A DNR order in the medical record of a patient who had been lingering near death for days served to limit the type of work they would do if a patient began to die. Without a DNR order, however, residents were obligated to approach every complication aggressively, as if the patient were acutely ill rather than dying. For interns this could mean a significant number of hours spent in the middle of the night ‘working up’ an extremely sick patient or coding a patient who had begun to die, with other tasks and patients left untended.

If the physicians felt a patient was near death anyway and further treatment was futile, they saw these activities employed to prolong life at the end of life as a futile drain of their time, energy, and resources. Because the residents believed they could not help these patients in medically significant ways, these activities became a time-consuming and exhausting ‘exercise’ which, in their view, took away from active pursuit of what they perceived to be immediately useful and important activities: taking

care of patients they could treat or who could teach them something about the practice of medicine. This was particularly significant to the interns who were working in a pressured and demanding environment where they constantly had too much to do and insufficient time in which to do it. Consequently, in those restricted circumstances where a patient was going to die in a matter of hours or days regardless of treatment, where an attending physician had not discussed the possibility of a DNR order with a dying patient, or where a family persistently refused to acknowledge the futility of further treatment, negotiating a limited code became one means by which the residents attempted to guard themselves against what they perceived to be a futile drain of their time and resources. There was no evidence to suggest that residents contemplated intermediate codes deliberately to lighten their work load. Such considerations, however, even if not carried out, had the effect of strengthening their belief that in the face of overwhelming demands they could control to some degree the demands of their work and the amount of effort they would spend on people who surely would die despite their labors.

Implicit endorsement

In the examples of negotiated limited codes given above, the residents took matters into their own hands by essentially acting us if patients had been made ‘no code.’ This action represented some risk to the residents since attending physicians have legal responsibility for the treatment decisions of their house staff, including resuscitation decisions. Such a claim to the authority which is traditionally the province of the attending physician typically would be rejected within the hierarchical organization of the teaching hospital. Consequently, the negotiation of a limited code was an event that often remained informal, non-recorded, and hidden, awareness of its practice available only to a few. Even when this action was publicly acknowledged after the event, however, disciplinary action against the residents was often absent. It was a practice that, if not publicly approved, was sometimes implicitly condoned by senior physicians, possibly because it appeared in retrospect to be the best solution to a complicated and difficult situation. The resident quoted above, whose attending could not bring himself to write a DNR order for a patient who was effectively dead, commented on his fear of reprimand after he had conducted a limited code:

The nurses called me [when the patient suffered cardiac arrest], and they’re supposed to call a code! . I went in there and turned off the Levophed and the dopamine. That’s the only way I could think of handling it. I mean, I know I took a lot of responsibility on myself because I didn’t code him.. . . Well, the next morning it was presented at residents’ report, and I’m just sort of waiting to be screamed at or chastised or whatever.. . And no one said anything. They thought it was right, was appropriate. Of course it was appropriate! (Second Year Resident.)


CONCLCSlONS bypasses the very intent of the resuscitation guidelines: to honor the principle of patient (or surrogate)

The presence of limited codes on teaching hospital autonomy and to prevent physicians from making medicine wards has been criticized as deplorable, unilateral decisions about resuscitation by requiring dishonest and inconsistent with established ethical a joint decision-making process. It places health care principles [28, 321. Critics argue that they represent providers, patients, and families in the midst of a deliberately inadequate attempts at an activity where dilemma with vast moral and legal implications. At success is rare enough even when all efforts are the same time, however, requiring that futile CPR be expended [6]. Moreover, their ad hoc and vague offered to patients also presents a troubling ethical quality leads to confusion and misunderstanding, and dilemma for physicians. they place both physicians and nurses in legal jeop- The preceding analysis has illustrated two general ardy [6, 14, 19,3 I]. Slow codes have also been decried types of situations in which this dilemma arises as an example of the failure of physicians to face the and resident physicians have considered using limited demanding emotional and intellectual task of talking codes: cases of disagreement with family and cases about futility with patients and families, or to con- of disagreement with senior physicians. A number of front their own feelings about their patients’ deaths institutional policies have been suggested to better [28, 33, 341. These arguments against the ‘shading’ of resolve such disagreements, including hospital ethics codes were forcefully summed up in the words of this committees [27], better prior discussion of a patient’s physician: “At best, it is a waste of time and a failure of code status [6], clear documentation in the medical to face reality and hard decision-making; at worst, it record of the medical reasons for selecting among the is an ethical fraud” [33]. techniques of resuscitation [32], and recommenda-

While not denying the significance of these tions that physicians be allowed to withhold cardio- criticisms, this paper suggests that it is also important pulmonary resuscitation, without patient consent, for to consider the phenomenon of limited codes in their patients for whom it would be futile [4, 29, 661. These cultural context by examining how they have emerged suggestions are based on the hope that they could in response to a problematic aspect of contemporary reduce the need for partial resuscitation, in which clinical practice. Existing guidelines governing phys- less than a full effort to resuscitate a patient was ician behavior in the use of resuscitation do not made because a senior physician never made a clear adequately cover all those situations encountered by decision, because the physicians thought it would the house staff. In teaching hospitals, as with other placate a family, or because of the discomfort of bureaucracies, procedures are dictated by sets of family or providers in discussing DNR orders. While normative rules and codes of operating procedures these remedies may diminish the situations in which which are functionally necessary for the accomplish- negotiation of limited codes occurs, it is unlikely the ment of the activities and goals of the institution but practice will be eliminated as long as debates continue which invariably fail to apply to all situations. Do- throughout society about the use and limitation of not-resuscitate orders were developed in response life-sustaining treatment. Is there a limit to our to unnecessary resuscitation, yet situations develop obligation to save and prolong life? Whose view and

where agreement cannot be reached and patients and values should hold precedence in such decisions?

physicians alike are faced with the prospect of futile When do the burdens of treatment overcome its

resuscitation. benefits? It is these questions which provide the In these circumstances negotiating limited codes overall cultural framework for resident physicians’

has played a role in the work environment of resident negotiation of limited codes. physicians by giving them a way of restricting thera- _ peutic activity in those instances where they were Ackno~ledgemenrs-Different versions of this paper were

convinced a resuscitation attempt would be futile. presented at the 1988 and 1989 Annual Meetings of the American Anthroooloeical Association. in Phoenix.

By employing an informal procedure-a procedure Arizona and Wash;ngtoi DC. which was bv its verv nature is less rule-bound. more The research on which this study is based was part of

2 ,

flexible, and more situationally-based-house officers the Program for the Humane Care of the Dying Patient,

were able to act on their conviction that there some- Division of Medical Ethics. Department of Medicine,

times comes a point in the care of a patient beyond University of California, San Francisco, and was supported bv the Maureen Church Charitable Trust and the James

which medical interventions act less to prolong Picker Foundation. Support for data analysis came from acceptable life than to extend a miserable dying the Academic Senate aid School of Medicine, University of

process, and that when this point is reached, CPR California, San Francisco, and from the National Institute

should not be employed as the obligatory final on Aging Training Grant to the Medical Anthropology Program. Universitv of California. San Francisco (# 5 T32

attempt to sustain life. AGE004j-07). The -author is indebted to Barbara’ Koenig In giving house officers a way to circumvent official who directed the larger research project from which this

policy, the negotiation of slow codes reflects a srudy came and who shared responsibilities for data

cultural solution to difficult or unworkable circum- collection. In addition, the insightful comments on earlier

stances in clinical practice. It is a solution, however, drafts of this paper of Judith Barker, Margaret Clark, Linda Mitteness, F.W. Muller, Denise V. Rodgers, and the

which establishes its own moral dilemma because it anonymous reviewers are gratefully acknowledged.


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of their extensive exposure to the deaths of many AIDS patients, many of whom are similar in age and background to themselves. Limited codes may have occurred more frequently than reported here, but because of their informal and verbal nature these events were not easily accessible to the researcher. Areen J. The legal status of consent obtained from 61. families of adult patients to withhold or withdraw treatment. J. Am. med Assoc. 258. 229, 1987. Since the primary focus of this research was on 62. physicians, nurses were not asked about their responses to the consideration of limited codes. In the cases reported here, nurses appeared to agree with, and 63. participate in, the limited code decisions which were made. Cushing M. ‘No code’ orders: current developments and the nursing director’s role. J. Nursing Admin. Xl, 22, 64. 1981. Clinician concern with liability in these matters is 65. expressed in a statement made by a physician to the President’s Commission for the Study of Ethical 66. Problems in Medicine and Biomedical and Behavioral Research [6]:

Older physicians are afraid of putting ‘do not resuscitate’ down because they are afraid of being sued for making a wrong decision. The younger physicians are anxious to put a ‘do not resuscitate’ down because they are afraid of being sued for making a wrong decision. The nurses will not act without a ‘do not resuscitate’ because they are afraid of being sued. [p. 2391. Lipton H. L. Do-not-resuscitate orders in a community hospital: Implications for quality care. Qua/. Rev. Bul. 13, 226, 1987. Youngner S. J. et al. ‘Do-not-resuscitate’ orders: Incidents and implications in a medical intensive care unit. J. Am. med. Assoc. 253, 54, 1985. Shelley S. I., Zahorchak R. M. and Gambrill C. D. Aggressiveness of nursing care for older patients and those with do-not-resuscitate orders. Nurs. Res. 36, 157, 1987. Lo B. and Jonsen A. Clinical decisions to limit treatment. Ann. hr. Med. 93, 764, 1980. Jonsen A. Do no harm, Ann. hf. Med. 88, 827, 1978. Tomlinson T. and Brody H. B. Ethics and communication in do-not-resuscitate orders. N. Engl. J. Med. 318, 43, 1988.

shades of blue: the negotiation of limited codes by medical residents

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