The question of whether a patient enrolled in hospice care can maintain “Full Code” status involves a complex intersection of patient rights, medical policy, and the philosophy of end-of-life care. Full Code status dictates that all measures, including cardiopulmonary resuscitation (CPR), mechanical ventilation, and advanced cardiac life support, must be used if a patient’s heart or breathing stops. This desire for aggressive intervention creates tension with the fundamental purpose of hospice: shifting the focus from curative treatment to comfort and acceptance of natural death. While the patient’s right to choose their medical care remains paramount, being Full Code in a hospice setting involves navigating significant ethical and logistical conflicts.
Understanding the Goals of Hospice Care
Hospice is a specialized form of palliative care designed for patients facing a terminal illness with a prognosis of six months or less. The overarching goal of hospice is to prioritize comfort, dignity, and quality of life, rather than pursuing treatments intended to cure the underlying disease. This care model focuses intensively on managing pain and other distressing symptoms, such as shortness of breath or nausea, allowing the patient to live as fully as possible in their final months.
The philosophy centers on supporting the patient and their family through the natural process of dying, providing emotional, spiritual, and medical support. Electing the Medicare Hospice Benefit requires the patient to waive Medicare payment for curative treatments related to the terminal illness. This foundation makes aggressive life-prolonging measures, like resuscitation, counterproductive to the comfort-focused plan of care.
The Policy and Practical Reality of Full Code Status
Legally, a patient is not required to have a Do Not Resuscitate (DNR) order to receive hospice services, even under the Medicare Hospice Benefit. Federal guidelines prohibit hospices from discriminating against patients based on their advance directive choices, meaning a patient can indeed elect Full Code status and still be admitted. Despite this legal allowance, choosing Full Code is an uncommon decision, with one study finding that approximately 12.9% of hospice patients retain this status.
The practical reality is that aggressive resuscitation attempts, such as chest compressions and intubation, are often traumatic and painful, directly violating the hospice standard of comfort care. For a patient with a terminal prognosis, the success rate of CPR is extremely low. If successful, it often results in severe complications like rib fractures or brain injury, leading to a significantly diminished quality of life. This conflict creates ethical dilemmas for hospice staff, who are trained to alleviate suffering but must respect the patient’s wish for full intervention.
If a Full Code hospice patient experiences cardiac arrest outside of a dedicated inpatient facility, the response can be complicated. Emergency Medical Services (EMS) personnel are typically bound by state or local regulations to initiate full resuscitation unless presented with a valid out-of-hospital DNR order. Even if hospice staff are present, their primary training leans toward comfort measures, creating a difficult situation where the patient’s choice for intervention clashes with the practical futility and discomfort of the procedure.
Advance Directives and Physician Orders
A patient’s end-of-life wishes are formally communicated through various legal documents, which serve different purposes in the medical setting. An Advance Directive, such as a Living Will, provides general instructions about future medical care, but it is typically not an immediately actionable order for emergency personnel. This document usually only takes effect when a patient is unable to communicate their own preferences.
In contrast, a Do Not Resuscitate (DNR) order is a specific, actionable medical order signed by a physician and placed in the patient’s chart. This order instructs all medical staff and, often, EMS personnel, not to attempt cardiopulmonary resuscitation if the patient’s heart or breathing stops. Related documents include the Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST). These portable forms translate a patient’s preferences into physician orders that are valid across healthcare settings, communicating the patient’s code status into legally binding instructions for all providers.
Clarifying Resuscitation Options
The choice of code status is not strictly limited to the extremes of “Full Code” or “DNR.” A spectrum of options exists to allow patients more nuance in their end-of-life decision-making. One common alternative is a Do Not Intubate (DNI) order, which permits non-invasive resuscitation measures, such as cardiac drugs or chest compressions, but prohibits the placement of a breathing tube. Patients often choose DNI to avoid the complications and discomfort associated with mechanical ventilation.
Other options move further into the comfort-focused model, such as “Limited Scope of Treatment” or “Comfort Measures Only” (CMO). CMO, sometimes called “Allow Natural Death” (AND), means that the care team will provide aggressive treatment for symptom relief, such as pain medication or oxygen, but will not use any life-prolonging interventions. These intermediate choices allow patients to retain control over specific interventions they wish to avoid while still aligning their overall care goals with the comfort-centered philosophy of hospice.