Why Do The Frail Elderly Insist On Full Code Status?

As a hospitalist now for six years I can safely say that performing CPR and intubating failing bodies with old organs and chronic functionally debilitating disease is not only insane, it's torture. The worst near case of full code brutality occurred in a 97 year old lady who's heart stopped just 24 hours after a pace maker.  I walked into the room, saw a skeleton laying there and said no way. I'm not doing it. It didn't matter. She was already gone. It was the worst case of full code status I had ever seen. Patients can be full code. But many patients have no idea how to differentiate full code from allowing natural death.

For many, hearing the words do not resuscitate conjures up images of physicians giving up. That couldn't be farther from the truth. Not a day goes by where I'm not giving maximal support for severe medical conditions ranging from rapid atrial fibrillation to severe COPD and even when unstable hypotension causes  ischemic colitis. All of them are DNR.  For many patients, nobody has taken the time to describe their experience with what happens to elderly folks, in their situation, when we try to do everything and end up with nothing but pain and suffering.  If we asked patients whether they would want to be subjected to pain and suffering before succumbing to their death, you'd find that most would kindly decline our offer. If we asked them if they would rather die a natural and peaceful death, most would rally behind that thought.

The problem is, I will never be able to tell a patient or family that their loved one would survive a life threatening illness and return to an acceptable quality of life. Some, very few in fact, may. But most will not. Most will parish a hard a painful death, lingering for a few hours, days, perhaps weeks, delayed perhaps by heroic but brutal Western medical technology.

I hear now that Congress is reneging on their promise to pay physicians for discussions about end of life ethical issues and allowing natural death. That's a shame. For the 35 minutes I spent in consultation with the 92 year old patient and his son, I am given no financial compensation  under the coding rules of  the Medicare National Bank. I have perhaps saved the patient from a terrible future death. And as a side effect, I have saved the Medicare National Bank thousands, perhaps hundreds of thousands of dollars in futile end of life care. While CPT codes exist that provide compensation above and beyond the standard admitting time frames, if time thresholds are not met, no code can be submitted.

In essence, my 35 minutes, which I voluntarily spent discussing important issues with my patient and their family, is a freebie. You get what you pay for. Which in this are case are a scattering of dedicated physicians who will take the time to actually sit down and talk in depth about the realities of end of life cares, for free.

You will find very few physicians who have the time or energy to offer freebies to their patient. Agreeing to pay specifically for DNR/allow natural death counseling is probably the best bang for your buck the Medicare National Bank could have ever spent. And it is probably the most humane therapy we can offer the frail elderly.  And they just bailed like the political wimps. It's really quit sad. I probably gave an elderly patient the greatest gift we as physicians can give, an opportunity to die with dignity. And the Medicare National Bank has decided that politics is more important than avoiding CPR in patients with chronic perma-supine syndrome, as this palliative care ecard helps to explain.

"I know you want your mother to be full code, but she has perma-supine syndrome and CPR will only piss off her spine."

I know you want your mother to be full code, but she has perma-supine syndrome and CPR will only upset her spine doctor ecard humor photo.

Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

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