December 12, 2014

'Code Comfort'—like a 'Code Blue', but for patients with DNRs

Daily Briefing

    Health care workers at Novant Health have implemented an alternative to "code blue" for patients with Do Not Resuscitate (DNR) orders that focuses on easing pain and suffering, two executives write in the Harvard Business Review.

    Too frequently, DNRs cause suffering for patients who do not receive urgent responses to their suffering, argue Melissa Phipps, Novant Health's assistant general counsel, and John Phipps, Novant Health's executive VP. "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 write.  

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    To address this issue, Novant pallatative care manager Cynthia Coleman created the "Code Comfort," drawing from experience as a hospice nurse to develop a new approach that aims to aggressively and immediately relieve pain. The response is much like a "Code Blue," when all hands are on deck to help a patient who stops breathing or loses a pulse.

    The clear, pre-planned teamwork process outlines reactions to various painful situations and is used for DNR patients who only want comfort measures taken. For example, instead of intubating a patient having severe difficulty breathing, they would give oxygen and morphine and elevate his or her head. In addition, a fan may provide a breeze, and the care providers may take other measures to ease the patient's anxiety.

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    Moreover, "Code Comfort ensures that no patient or family suffers alone," the Phipps write. Nurses remain present the entire time, calling in other team members as needed—such as respiratory therapists, chaplains, palliative care physicians, or others who address both the physical and emotional pain of the patient and family.

    "It is a compassionate way to manage pain and suffering—including emotional suffering—during an acute crisis without providing unwanted care," the Phipps write.

    IOM: We need to modernize America's end-of-life system

    The code gives staff on the floor the ability to manage patient symptoms proactively and reduces stigma surrounding "DNR," they argue. With it, patients and their families are not forced to decide between "all or nothing."

    However, the Phipps caution that a DNR status does not automatically mean the patient wishes to receive only comfort measures—in fact, that is the case for just 50% of DNR patients, according to the National POLST Paradigm (Melissa Phipps/John Phipps, Harvard Business Review, 12/9). 

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    More from today's Daily Briefing
    1. Current Article'Code Comfort'—like a 'Code Blue', but for patients with DNRs

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