The full code reversed

Today the skilled nursing facility, or SNF as we say, sent in a 95 year-old with like a million medical conditions. She was lethargic and had low blood pressure. This indeed was true. As I held the face sheet transfer document with meds, vitals, medical conditions from the SNF, I eagerly scan for the "code status."

FULL CODE. 95 years old. Should have died years ago. And now in my ED where I have all kinds of technology, which are either instruments of life support or instruments of torture depending on the patient.

I don't know what's going on. Probably dehydration, but she's ancient and has problems with every organ, so anything could be wrong. Heart failure? Sure. Kidney failure? Sure. Infection? Absolutely. Thyroid issue? Possible. Simple dehydration? Quite possible. Medication over-use? You bet.

She doesn't perk up with simple IV fluids, but she doesn't swirl around the drain either. She's arousable and talks in disoriented, demented sentences.

I call her health care proxy, the son. "She doesn't want any machines," he tells me. But if her heart stops? "Well then I guess we should make an effort to keep it going." We hear this a lot in medicine. "Try." It seems sane. Seems just. Seems humane. I explain that CPR is brutal and painful. I explain that if a 95 year hold has a cardiac arrest there is virtually no chance of CPR working well and even if so, she ain't going to be walking in a field of daisies. It will be life support and a slow miserable, prolonged death. Well I say that in so many words. But I do my best not to mince words and sugar coat. I've seen too many docs do that because it is easier to say it like that. But honestly, I think patients and their families always appreciate the straight and narrow honesty, even if the truth hurts a lot.

So he agreed that cardiac resuscitation was not reasonable and not what she would want. I've played out these conversations over and over again in my head to get it just right. So much hinges on the way things are phrased, tone, timing.

So what this meant is that the patient was admitted to the regular floor, not to the ICU. This kept a very expensive and valuable ICU bed open for someone who will much, much more likely benefit from life support. And it kept her family - and the rest of us since he bill will be nearly 100% from medicare - from paying thousands of dollars of health care that would much, much more benefit another patient.

This is humane. And it is rationing. And it is rational. Most importantly it is respecting HER wishes, rather than playing into the feeling of guilt that many family members feel when letting go. These situations are never easy, but this one was relatively straight-forward. It gets hard when this same patient is 75, or even younger with a worse disease and worse prognosis.