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When Death Approaches

The Misunderstood Code

A quick glance at the cardiac monitor confirms what we already suspect. The old man is dying. My staff looks at me expectantly. We are all thinking the same thing.

"I sure wish we knew his code status!" One of the nurses gets it out in the open.

Another nurse observes, "Something feels wrong with trying to code this man. I wish we could just let him die in peace!"

"Should I get the code cart?" asks the tech. He is referring to a tool chest filled with drugs and equipment.

I find myself longing for the old days of medicine when this bastardized word-code--referred to honor and ethics. Now, medical personnel universally recognize the "code" word as it pertains to those last-ditch efforts we make when a person is dying. In this context, a code refers to three main things: inserting a plastic tube in the dying person's throat and attaching the tube to a ventilator (a machine that breathes for the person); giving potent medications to stimulate and regulate the heart's pumping action; and, often, using an electric shock to restart a dying heart. In sloppy modern vernacular, the word is also used as a verb referring to these actions; e.g., "We coded him for three hours!" or an adjective as in "code team" or "code drugs."

In our culture's obsession with success, we have come to view death as the ultimate defeat. As technology has developed, doctors have come up with amazing ways of staving off the inevitable end. The code is one result of this technology. The problem is that we still have much to learn about when to use a code appropriately.

When a code is successful and a dynamic life is pulled from the jaws of serious injury or illness, it is an awesome accomplishment. When a code fails, there are two possibilities. One is death. The other is a fate many would consider worse than death. In the process of dying, irreversible damage occurs, most often to the brain. The code leaves the person in a state less vigorous than life and less peaceful than death. The words "dementia" and "vegetative" are often applied. In our passion for prolonging life, we too often succeed in prolonging agony and infirmity.

With all this talk of codes, you might think that these attempts to save a life are a huge secret. In a sense this is true, but not in the way you might think. Through the questionable wonder of television, most Americans are now privy to our code. The drama is played out weekly on different hospital sets. Routinely, these shows depict the engaging theme of the tragic patient who is teetering on the brink of death only to be rescued at the last possible second by miracle-working doctors. Therein lies a serious problem.

The fallacy of such TV dramas is that most of their codes succeed, few patients die, and only rarely does the patient survive in a demented or vegetative state. The reality is that relatively few codes succeed, many people die, and all too many are doomed to weeks, months, or years of confinement in their damaged bodies and brains.

The dilemma is that as doctors, we have no prognostic tests to help us decide when to use the code. Even though we realize the frequent futility of these efforts, it remains a difficult decision for families and loved ones to let go and give us permission for "No Code." This choice is all the more difficult when the illness is sudden or unexpected.

How can people decide when it is appropriate to use "the code"? I encourage you to think about your attitudes toward this subject. Would you be ready to make the decision if a loved one was suddenly dying? Code or No Code?

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