Living Wills & DNR: Is Patient Safety Compromised?

Human Life Review, Fall 2007 by Mirarchi, Ferdinando L, Conti, Lucia

Full Code

A full code is the most extensive course of treatment. It communicates to the physicians that all measures should be taken to keep the patient alive. The patient is considered safe when her code status is full code.

Hospice Care/Comfort Care

A hospice-care/comfort-care code status communicates that the healthcare personnel should allow nature to take its course and let the patient die naturally. The main goal of the clinician should be to make the patient as comfortable as possible and relieve any pain or anxiety the patient may be experiencing. When a patient is designated under the hospice-care/comfortcare code, she is presumed to be relatively safe.

Slow Code

The slow-code designation applies in situations where it is easier to delay treatment than to determine what level of treatment the patient desires. Often this code designation is applied to patients who do not appear to benefit from any medical care, and health-care personnel therefore provide comfort care, in the expectation that the patient will die before questions about her health-care wishes arise. This code status is unsafe for patients.

No Code

The no-code designation is similar to a DNR, as it requests that no lifesaving measures be taken by the health-care personnel. Often though, the no-code designation is found too vague to be useful, and can be confusing to the clinician. Therefore, the no-code designation is unsafe for patients.

Chemical Code

The chemical code communicates that the patient wants to be treated only with medication, and that therefore no CPR, insertion of tubes, invasive procedures, or other therapies are to be performed. The problem with this code status arises when most medications that need to be given cannot be administered effectively without the use of the other unwanted procedures. Therefore, the chemical code is unsafe for the patient to use.

DNI

Patients who designate their code status as a DNI-do not intubate-are requesting not to be placed on a ventilator for a long period of time. It is a common mistake among clinicians, though, to suppose that the DNI code status means the patient is requesting never to be intubated, even for a short period of time. Therefore, the DNI code status is unsafe for patients.

DNR

As the name implies, the DNR code status communicates to the healthcare personnel not to attempt to restart the patient's heart or breathing once they have stopped. Often, the DNR code status is chosen by patients who are nearing death and have expressed that they do not wish to be kept alive by heroic means. The DNR code presents many problems for physicians and health-care personnel and therefore is an unsafe code designation for any patient.

The problems with DNR orders escalate as many clinicians believe that patients with living wills are also of DNR code status. This is not correct; a living will is not the equivalent of a DNR order and furthermore, a DNR order does not mean "do not treat."

Not only should a patient understand and include the code status, but she should also understand when the living will is to be utilized. There is a difference between when a living will is effective and when a living will is enacted. A patient's living will becomes effective when the patient has completed the living will and has signed it in the presence of a witness in compliance with the requirements of the state. The living will's effectiveness means that the living will exists and can then be enacted when the specified triggers, outlined in the document, have occurred.