Advance care planning ensures that a person’s values and preferences for medical intervention are known and respected, even if they become unable to communicate. This process allows patients, or their legally appointed representatives, to define the precise limitations of care they are willing to accept in a hospital setting, often formalized through a designated “code status.” Establishing this status guides medical teams in emergency situations and provides clarity during challenging moments of care.
Understanding Medical Code Status
A patient’s “code status” is a medical order establishing the plan for intervention during a cardiopulmonary arrest (when the heart or breathing stops). The most aggressive option is a Full Code, meaning the medical team will deploy all available measures to attempt resuscitation. This includes cardiopulmonary resuscitation (CPR), electrical defibrillation, and emergency cardiac drugs to restart the heart.
The Do Not Resuscitate (DNR) order is a physician’s directive stating that CPR will not be attempted if the patient’s heart stops beating or their breathing ceases. A DNR specifically prohibits chest compressions, defibrillation, and the administration of emergency resuscitative medications used during a cardiac arrest event. This order is designed to prevent invasive interventions when a person is nearing the end of life or has a condition where resuscitation is unlikely to be effective.
A Do Not Intubate (DNI) order is a specific limitation that may be used alongside or separate from a DNR. Intubation involves placing a breathing tube into the patient’s windpipe, connecting them to a mechanical ventilator. A DNI order means that while other life-saving measures, such as cardiac medications, might still be allowed, the patient refuses the use of a breathing tube and mechanical ventilation.
The Scope of the Orders: What Care Continues
A common misunderstanding is that a DNR or DNI order signifies a withdrawal of all medical treatment. These orders are highly specific, focusing only on resuscitation, and are not the same as a “Do Not Treat” order. All other appropriate medical care continues uninterrupted.
The hospital team maintains treatment for underlying conditions, including administering antibiotics for an infection, providing insulin for diabetes, or managing blood pressure. The patient will still receive diagnostic tests, such as blood work or imaging, to monitor their health status.
Comfort care is always administered, regardless of the patient’s code status. This includes aggressive pain management, symptom relief for shortness of breath or nausea, and emotional support. The focus of care simply shifts from attempting to restart a heart or breathing to ensuring the person’s comfort and dignity throughout their illness.
The distinction between treatment and resuscitation is important. If the patient has a DNR-CC (Comfort Care) order, only comfort measures will be administered before, during, or after the heart or breathing stops. Conversely, a DNR-CCA (Comfort Care Arrest) order permits life-saving treatments up until the point of arrest, at which time only comfort measures are provided.
How Code Status Decisions Are Made and Documented
The process of establishing a code status begins with a thorough conversation between the patient and a physician or qualified provider. This discussion centers on the patient’s overall prognosis, their personal values, and the expected outcomes and burdens of resuscitation measures.
Patient autonomy means a mentally capable patient has the right to decide what medical treatment they accept or refuse. If a patient is unable to make this decision, their legally recognized surrogate, such as a healthcare proxy or agent designated in an advance directive, must speak on their behalf. The physician then writes the chosen status, such as DNR or DNI, as a formal medical order in the patient’s chart.
For the order to be effective outside of the hospital, such as in the home or during ambulance transport, specific documents are necessary. These are often called Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST), though the name varies by state. Unlike general advance directives, which outline wishes, POLST/MOLST forms are actual physician orders signed by a provider and the patient or surrogate. These portable medical orders translate a patient’s preferences into actionable instructions for any healthcare provider, including Emergency Medical Services (EMS) personnel. Having a POLST or MOLST ensures the code status decision is honored across different care settings and is legally binding for first responders.