Caffeine’s effect waned, stomachs rumbled, attention spans faded after rounding on nine acutely ill patients on university wards. It was nearing lunch. I was the senior resident, so I chose the order in which we saw patients. As we arrived at our last patient’s room, I snapped out of my under-caffeinated daze and realized I had made the rookie mistake of leaving our newest and sickest patient for last.
Mr. Krauss transferred from the ICU the previous night. The ICU team admitted him two weeks prior for respiratory failure from rapidly progressive rhabdomyosarcoma, metastatic to his lungs and bones. Pneumonia, sepsis and severe bone pain complicated his course. Eventually his oxygen needs improved. He was able to transfer to the floor on an oxymask. We gathered outside his room, and the intern presented the overnight events — code status updated to Do Not Resuscitate (DNR), then back to full code — then the subjective complaints (pain, pain, pain), followed by the vital signs (pulse 110, oxygen saturation 94% on 10 liters by oxymask). He paused for input from Katie, the bedside nurse.
“We only accepted him from the ICU because we thought he was a comfort care patient.” She crossed her arms.
“He was DNR, now he’s full code and should go back to the unit.”
Mr. Krauss told the ICU intern he did not want resuscitation, and he changed his code status to DNR. However, when I met him, he and his five brothers were adamant that he did want resuscitation.
Katie said, “When he was DNR it was fine for him to be on the floor because he was a comfort care patient, but now you made him full code.”
My face turned red and warm, betraying my frustration. The source of my befuddlement was equating a code status of “do not resuscitate” with a treatment plan of “comfort measures.” Invoking code status only applies in one situation, cardiopulmonary arrest. It says nothing about the treatment a patient wishes to receive or not receive. When a patient does not want interventions to prolong life, we can initiate comfort measures to alleviate distressing symptoms.
Before I met him, Mr. Krauss had made it clear to his family and clinicians in palliative medicine, oncology, and the ICU that his goal was to get well enough to receive chemotherapy. From the medical team’s perspective, this was unlikely to happen. Doctors discussed options of comfort care or hospice with him, and he adamantly declined.
I composed myself and returned to the conversation on rounds. I explained that although his code status was DNR, he wanted whatever life-prolonging treatment was available to him. This is not consistent with comfort care. Katie nodded and proceeded with her assessment. We made a detailed plan and concluded rounds. I circled back with Katie later to make sure she was comfortable with his plan of care.
She said, “I can’t believe I confused DNR and comfort care.”
I acknowledged that these terms are tricky to grasp, and at times they all feel interchangeable. I wanted to get a sense of how commonly misunderstood DNR and comfort measures were. I found an online nursing forum discussing the distinction between a DNR code status and other treatment plans. Entitled “DNR Help,” the thread opened with a question about the difference between DNR and comfort care. There were thoughtful comments by nurses and paramedics, but also some glaring misunderstandings.
For example, one person posted on the thread, “I will not put a DNR patient on pressors…A DNR patient who is hypotensive is trying to die, LET THEM.”
To be sure, this confusion extends across the spectrum of health care providers, including physicians, nurses, and paramedics. An article entitled “Do not resuscitate does not mean do not treat“ cited several studies of physician practices and showed that patients with DNR orders received fewer life-prolonging treatments such as dialysis, intubation or antibiotics, even when they are indicated.
If those of us in health care are confused about the terms advance directive, POLST, code status or comfort measures, imagine patients’ and their families’ confusion. We all need more education about the spectrum of end of life planning. The solution to overcoming these misunderstandings also requires better communication. We need to talk, really talk, with patients about their goals of care. Asking “Would you want CPR?” and extrapolating to other aspects of care is simply not enough.