Healthcare Directives and Code levels are not the same. A Healthcare Directive takes effect if the patient is unable to express their wishes. This is a serious decision which allows the patient to be an active participant in their medical care while they are still able to do so. The Healthcare Directive is a document that states the patient’s medical considerations regarding life sustaining interventions for the future or should they become unresponsive.
Code Levels are determined by the patient’s medical considerations regarding life-sustaining intervention.
Admission: When admitted, a physician will initially discuss with the patient what life-sustaining treatments are available and what their desire is for these treatments. Below are some points considered when making decisions:
- Why are you in the hospital? » What is your health status now and the foreseeable future?
- What is your desired quality of life?
- What are your personal values?
- Is your condition/situation reversible?
- Would continuation of treatments be medically ineffective?
POLST (Physician’s Orders for Life-Sustaining Treatment) is a physician order that documents and directs the patient’s medical considerations regarding life-sustaining interventions (i.e., Code Level). The POLST is used not only as an agreement between the physician and the patient, but it is used for the present situation as well as for the future. It may be updated and reviewed at any time.
The POLST takes the following into consideration:
- DNR or CPR - only if the patient has no heart beat and is not breathing.
- Artificial Nutrition: When a patient can no longer eat or drink by mouth. Liquid food can be provided to them through a tube.
- Intravenous Fluids (IV): A small plastic tube (catheter) is inserted directly into the vein and fluids are administered through the tube. Typically, IV fluids are given on a short-term basis.
- Tube Feeding: On a short-term basis, fluids and liquid nutrients can be given through a tube in the nose that goes into the stomach (nasogastric or “NG” tube). For long term feeding, a tube can be inserted through a surgical procedure directly into the stomach (gastric or “G” tube) or the intestines (jejunal or “J” tube).
- Antibiotics: Antibiotics treat some infections (such as pneumonia) that can develop when a patient is seriously ill.
- Mechanical Ventilation/Respiration: When a patient is no longer able to breathe on their own, a tube is put down the throat to help breathing. A machine pumps air in and out of the lungs through the tube.
- Comfort Measures: Care provided with the primary goal of keeping a patient comfortable (rather than prolonging life). A patient who requests “comfort measures only” would be transferred to the hospital only if needed for his or her comfort.
- Medically Ineffective: Any course of treatment that offers no beneficial outcome or is medically ineffective and contrary to generally accepted healthcare standards. This judgment is based on standards of medical care, recognizing the uniqueness of patients and diseases and weighing the relevant medical literature, opinions of consults, clinic experience, patient’s wishes, and patient’s determinations of quality of life.
- Dialysis: You have the right to make your own choices about how you are treated for kidney failure. That means you can choose when to start or stop dialysis.
Who should have a POLST?
- If you have a serious health condition and need to make advance decisions about life sustaining treatment here and now. Your physician or nurse practitioner can use the POLST form to represent the patient’s wishes as a clear, specific written medical order.
- The form must be signed by a physician or nurse practitioner for it to be followed. Other health care professionals can complete the form, but it requires a physician, or nurse practitioner signature.
I have a Healthcare Directive - Do I Need a POLST?
- Yes, it is recommended. It reflects your desires here and now. It will be discussed by a member of the healthcare team if there are changes in the medical condition.
- At any point of care you have the right to review and change your code level/POLST.
Code Levels:
- Full Code: defined as full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat and is not breathing.
- DNR: The patient does not want CPR the person has no heart beat and is not breathing, but may want other life-sustaining treatments.
- COMFORT CARES ONLY: defined as end of life care, with emphasis on comfort care. This treatment includes a patient’s physical and/or emotional comfort. Comfort care always includes adequate pain control. At this point, medications and treatments for cure attempts are discontinued. No attempts will be made for resuscitation (i.e., DNR) and allows natural death. Everything will be done to provide comfort and dignity for the patient and family.
- Cardiopulmonary Resuscitation (CPR): Refers to the medical procedures used to attempt to restart a patient’s heart and provide oxygen if the patient suffers heart failure. CPR may involve efforts such as mouth-to-mouth resuscitation and external chest compressions. Advanced CPR (or ALS Advanced Life Support) may involve electric shock and/or insertion of a tube to open the patient’s airway and hooked to a ventilator to support breathing until the patient can breathe on their own. Medications may be required to regulate the heart and blood pressure. It is important to talk to your physician about chances of recovery and survival based on your medical condition.
- Do Not Resuscitate (DNR): This means that physicians, nurses and emergency medical personnel will not attempt emergency CPR if the patient’s breathing or heartbeat stops. The DNR tells medical professionals not to perform CPR. DNR would allow a natural death.
Please feel free to talk openly at any time to any member of your healthcare team.
