Having the conversation and knowing the end-of-life and medical wishes of your loved ones ensures dignified care and autonomy of their body.
The fish-and-water effect: a metaphor used to describe how one can be so immersed in their environment that they fail to appreciate one or more obvious aspects of their surroundings. One can then argue that we sometimes fail to appreciate our cognition which influences our ability to plan, problem-solve and make decisions. The significance of independence and autonomy is often overlooked until something happens—an accident, injury, or complication—in which one may be left with cognitive consequences. Especially for our loved ones, how would we know their true wishes if we did not discuss it previously? This situation perfectly highlights the significance of Advanced Care Planning (ACP), which according to Advanced Care Planning Canada (ACPC) is the process of thinking and talking to your loved ones, providers and/or any other significant individuals about your wishes, desires and values related to your health. It creates a vision of what personal care looks like to you. Although ACP consists of many elements, my experience as a nursing student has drawn me to focus on code or resuscitation statuses while being under hospital care. According to Covenant Health, code statuses are described as the type of treatment individuals want in life-threatening situations, including CPR, tracheal (windpipe) intubation, critical care management, and more. In this article, I hope to highlight the significance of discussing personal wishes and ACP with loved ones to ensure proper, individualized and dignified healthcare.
The advanced care plan consists of many components which include one’s resuscitation status. As indicated by Covenant Health, London Health Sciences Centre and Halton Healthcare, there are four categories associated with a hospital code status: cardiopulmonary resuscitation (CPR), defibrillation, vasoactive (cardiovascular-activating) medications as well as intubation and mechanical ventilation. CPR refers to chest compressions which pump the lungs and heart with the hope of physically restarting the heart. Defibrillation, commonly using an automated external defibrillator (although implantable cardioverter-defibrillators [ICD] also exist in vulnerable populations), can only be used on certain heart rhythms with the hope of electrically restarting heart conductivity. Vasoactive medications, including epinephrine (found in epipens), are used in an attempt to chemically restart the heart with its cardiovascular-stimulating drug activity. Lastly, respiratory efforts such as intubation and mechanical ventilation aim to facilitate the patient’s breathing. Intubation requires the insertion of a tube down the windpipe to maintain an open airway, while mechanical ventilation uses oxygen to invasively (through a tube connected to a ventilator) or non-invasively (through a facial mask or nasal prongs) support breathing.
Across hospitals, levels of code statuses vary, meaning the resuscitation efforts involved vary in grouping as well as the number and diversity of such levels. However, I will first review the three common levels found across hospitals (although names may vary): full code, do not resuscitate (DNR) and comfort care. Full code refers to all curative efforts while alive and all resuscitation efforts during cardiac and respiratory arrest. DNR refers to all curative efforts while alive but (generally) none of the resuscitation efforts. Comfort care refers to comfort measures (not necessarily focusing on “curing”) and no resuscitation efforts. However, comfort measures during end-of-life care may be provided including oxygen and mouth/throat suction to remove any substances causing discomfort. As I said before, levels of code statuses vary as some hospitals provide more individualized preferences in their care. In discussing my article with my clinical tutor, she mentioned how one of her previous students described such preferences as ice cream toppings—you start with a plain ice cream and you can add as many or few toppings as you’d like. An example of this is shown by the London Health Sciences Centre through their resuscitation form to be completed by every admitted patient at the time of admission. It allows people to choose different types of care regarding resuscitation and life-threatening treatment, with options for preferences regarding antibiotic and IV fluid use, intubation, vasoactive medication, mechanical ventilation and more. The expanse of options allows patients to create a more individualized and dignified form of care for themselves as well as provide legal protection for such medical preferences.
According to ACPC’s 2021 national poll, 93% of people in Canada believe it’s important to talk to their family and friends about their healthcare wishes, yet only 1 in 5 of them have a plan. Although this article may have provided you with knowledge and the significance of ACP, it’s not enough to stop here. Have the conversation with your loved ones, whether it be uncomfortable or tough, to ensure their medical wishes are respected. It is important to have this conversation intra- and inter-personally. ACP starts the process of thinking and learning about different options and possible wishes to ensure dignified care for, most importantly, yourself. Hospital code statuses are only a fraction of what can be included in an advanced care plan, with other components including choosing substitute decision makers and documentation of one’s advanced care plan. I hope you learned something new from this article and continue the conversation about the significance of ACP!🫂