Code Comfort: A Code Blue Alternative for Patients with DNRs

by  Melissa P. Phipps  and   John D. Phipps   DECEMBER 9, 2014

“Do Not Resuscitate” (DNR) does not mean “Do Not Treat,” but dying patients who have chosen a DNR order often feel abandoned, whether they are at home or in the hospital. In the hospital, nurses caring for patients with DNR orders do their best to ease their suffering, but rarely know how to manage such suffering for patients who don’t want aggressive treatments. Why is it that when a patient wants to have “everything done,” we literally run to resuscitate them if needed — and yet, when a patient with a DNR order urgently needs comfort, we rarely respond with urgency?

Even when nature is taking its course, it is a crisis for patients and their families when the dying suffer from pain, trouble breathing, or panic. They deserve a response that reflects their sense of urgency — and so do those taking care of them. At Novant Health, we realized that patients and their loved ones often feel that they are faced with the impossible choice of either accepting unwanted aggressive interventions or suffering without treatment. We have seen families reverse a patient’s DNR or “do not intubate” (DNI) order when the patient was in distress, just to relieve their loved one’s suffering. Cynthia Coleman, one of our palliative care managers, imagined a different choice. She drew on her prior experience as a hospice nurse and worked with colleagues to develop a novel approach to suffering patients who urgently need relief. We call it “Code Comfort.” The term was chosen because it sends a clear message that when a patient is suffering, it is everyone’s top priority.

We’ve all seen on television what happens when a patient’s heart and breathing stops. Someone yells, “He’s crashing!” or “Get the crash cart!” or “Code Blue!” Then the “code team” runs down the hall. Someone starts CPR, someone else inserts a breathing tube, then someone yells “Clear!” and the patient is shocked with paddles to restart the heart.

Code Comfort is like a Code Blue, but the aim is to provide immediate, aggressive relief of suffering. It is a clearly defined process that requires rapid-response teamwork. For example, if a critically ill patient can’t catch her breath and feels she is suffocating, it’s a terrifying experience, and caregivers are often at a loss if they don’t have a plan to intervene. Coleman knew of numerous measures for patients suffering from breathing difficulty (dyspnea), pain and agitation that didn’t require invasive procedures such as intubation. She realized that these measures could be offered in the same immediate, pre-planned way CPR is performed.

Code Comfort provides a response for patients whose code status is DNR and who desire comfort measures only. It is a compassionate way to manage pain and suffering — including emotional suffering — during an acute crisis without providing unwanted care. Hospital staff responding to a Code Comfort may include palliative care physicians, nurses, respiratory therapists, chaplains and others who are prepared to rapidly address the patient’s physical symptoms, as well as the suffering and concerns of family members.

As is true for CPR efforts, we know teamwork matters to relieve the suffering of dying patients. Code Comfort protocols include an algorithm-driven method for assessing and addressing symptoms such as pain, agitation and dyspnea. For example, a patient suffering from severe, acute dyspnea would be given morphine and increased oxygen, her head would be elevated, a fan might be used to provide a comforting breeze, and she’d receive other measures to reduce anxiety. Importantly, Code Comfort ensures that no patient or family suffers alone. Nurses are present during the code, actively treating the patient’s symptoms and calling in other team members as needed, all of which provides essential emotional support and reassurance. (See Novant Health’sCode Comfort order set and draft policy here.)

Providers considering implementing Code Comfort need to be mindful that DNR status alone does not necessarily reveal the patient’s wishes related to other treatments. For example, data from the National POLST Paradigm (an approach to end-of-life planning) shows that only 50% of patients with a DNR order also choose comfort measures only. Conversations with patients and families regarding goals of care — whether the patient wants full interventions, limited interventions or comfort measures only — are imperative to successful implementation of Code Comfort. These additional questions form the basis of portable medical orders (known as POLST, POST or MOST). As we launch additional pilots and prepare to implement Code Comfort across our system, we will be laying the foundation by providing DNR education and encouraging greater use of portable medical orders.

Code Comfort empowers front-line staff to proactively manage patient symptoms, which hopefully will prevent an acute symptom crisis. It reduces the stigma of “DNR” by focusing on what we will do rather than what we won’t do. It spares patients and loved ones from having to choose between “all or nothing.” And, above all, it relieves suffering.

 https://hbr.org/2014/12/code-comfort-a-code-blue-alternative-for-patients-with-dnrs