Code status represents a fundamental decision a patient makes regarding the extent of medical intervention they wish to receive in the event of a life-threatening crisis, such as cardiac or respiratory arrest. This medical designation guides healthcare providers on how to proceed during an emergency, ensuring a patient’s values and preferences are honored. Code status discussions are part of comprehensive advance care planning, allowing individuals to determine the level of care they desire before they are unable to communicate. These decisions involve weighing the potential benefits of aggressive life-saving measures against the potential burdens and outcomes.
Defining Do Not Resuscitate and Do Not Intubate
The term Do Not Resuscitate (DNR) is a medical order instructing healthcare professionals to withhold cardiopulmonary resuscitation (CPR) if a patient’s heart stops beating or they stop breathing. A DNR order specifically means no chest compressions, no electrical shocks (defibrillation), and no emergency cardiac medications will be administered. The focus of this order is to prevent the aggressive measures used to restart the heart and breathing during cardiac arrest.
The Do Not Intubate (DNI) order is a separate instruction that prohibits the placement of an endotracheal tube, which connects the patient to a mechanical ventilator. Intubation is often performed to manage severe respiratory failure, a condition distinct from cardiac arrest. A patient may choose a DNI order to avoid the invasiveness and potential complications of prolonged mechanical ventilation, even if they would otherwise want other interventions.
The distinction is important because a patient can have a DNI order while still permitting other aggressive treatments, such as intravenous fluids, antibiotics, or even chest compressions and defibrillation if their heart arrests. However, a full DNR order generally encompasses the DNI instruction, as intubation is a standard component of a complete resuscitation protocol. When a patient has a DNR, all components of the traditional resuscitation response are withheld.
The Full Spectrum of Code Status Options
While DNR and DNI are common terms, code status is not simply a binary choice. The default status in any healthcare setting is “Full Code,” which mandates maximal efforts to restore heart function and breathing, including CPR, intubation, and all available emergency medications. This status represents a preference for life prolongation without limitation, regardless of the patient’s underlying condition or prognosis.
On the opposite end of the spectrum is “Comfort Measures Only,” sometimes referred to as Allow Natural Death (AND). This designation shifts the focus of care away from curative or life-prolonging treatments toward managing pain and other symptoms to maximize comfort. With a Comfort Measures Only status, all forms of resuscitation are prohibited, and aggressive interventions like new surgeries or intensive care unit admissions are avoided.
In between these two extremes, patients may choose a “Limited” or “Modified” Code status, though these are sometimes discouraged due to complexity and potential for confusion. A limited order allows the patient to select specific interventions they would accept while excluding others. For instance, a person might choose to receive ventilatory support and medications but refuse chest compressions, or they might accept non-invasive breathing support like a BiPAP machine but still refuse intubation.
Establishing and Documenting Code Status Orders
Establishing a code status order requires a detailed discussion between the patient or their legally authorized surrogate and a physician. This conversation centers on the patient’s goals of care, values, and understanding of the potential outcomes and burdens of various interventions. The physician ensures the patient has a clear, realistic understanding of their medical condition and the likelihood of success for any given intervention.
The final code status is documented as a legally binding medical order within the patient’s chart, not just a preference. Advance Directives, such as a Living Will or a Durable Power of Attorney for Healthcare, provide guidance by outlining a patient’s general wishes and appointing a surrogate decision-maker if the patient loses capacity. However, these legal documents alone are often not sufficient for immediate emergency action.
Many states utilize specific physician-signed forms, generically known as Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST). These forms translate the patient’s preferences into actionable medical orders covering a range of interventions, including CPR, intubation, feeding tubes, and antibiotic use. The use of these standardized forms ensures the patient’s wishes are clearly understood and legally enforceable across various healthcare settings.
What Happens When Code Status Orders Are Activated
When a patient experiences cardiac or respiratory arrest, the first action of the healthcare team is to quickly verify the patient’s documented code status. If a valid DNR or DNI order is in place, providers immediately refrain from initiating the prohibited resuscitative measures. For a patient with a DNR order, this means the emergency team will not begin chest compressions, administer electric shocks, or give emergency drugs aimed at restarting the heart.
A DNR or DNI order does not mean that all medical care stops; instead, it directs care toward comfort and non-resuscitative interventions. The patient continues to receive all other appropriate medical treatment, such as pain control, symptom management, and monitoring. These orders are not fixed and are subject to continuous review, allowing the patient or their surrogate to change the code status at any time if their medical condition or preferences evolve.
For patients outside of a hospital, a specific out-of-hospital DNR or POLST form, often signed by a physician and sometimes displayed on a bracelet or card, ensures portability. This documentation allows Emergency Medical Services (EMS) personnel to honor the patient’s wishes in the field, preventing the initiation of unwanted resuscitation before the patient reaches the hospital. The established code status travels with the patient, providing continuity of care that aligns with their personal choices across different environments.