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Code Orders

If patients indicate, either verbally or in writing, that they do not want CPR, their attending physicians should indicate this as an order in the chart. Every hospital should have a system of marking charts so that it will be obvious when there is a no-code order. Frequently, a code will be called before anyone realizes that there is an order to the contrary. As soon as the chart is found and the order noted, the resuscitation is stopped. This is not the same as stopping the resuscitation because the patient is dead. The fact that there may be respiratory efforts in the absence of a pulse, or vice versa, is not justification for countermanding a no-code order.

All no-code orders should be in writing, and the consent of the patient or guardian should be documented. Ideally, the patient or guardian will sign the order for no CPR. As with other consent to medical care, the family should not be involved without the patient's permission. In reality, this may not be possible. Patients who are no longer mentally competent cannot make their wishes known. (See Chapter 11.) If the care of an incompetent patient must continue over a period of days or weeks, then a court-appointed guardian should be obtained to make consent decisions.

Resuscitation is not always an all-or-none action. Both a patient and a physician may limit the extent of a code. A patient may want to be revived if independent existence is possible but not if a respirator would be required. A physician may make the same decision based on whether the patient is medically a candidate for a respirator. The prescribing of respirator support is a medical decision. There is no requirement that a patient be put on a respirator, and it is poor practice to prescribe a respirator for a patient who is unlikely to be weanable. Like a no-code order, any limitations on resuscitation should be well documented in the chart and well known to the caretakers.

There is no such thing as a slow code. Physicians must not use informal mechanisms to deny patients medical care. If there is not a no-code or limited-code order in the chart, every reasonable effort must be made to revive the patient. A nurse or resident should never accept an order or a hint to take it slow on a particular patient. If the attending physician thinks that the patient is not a good candidate for CPR or other support measures, the physician should discuss this with the patient and write the appropriate orders. Physicians who will not properly document limited code orders must be reported to the appropriate hospital review committee.

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