Only One Thing You Can Do When They're “All Dead”

Miracle Max: See, there's a big difference between mostly dead, and all dead. Now, mostly dead: he's slightly alive. All dead: well, with all dead, there's usually only one thing that you can do.

Inigo: What's that?

Miracle Max: Go through his clothes and look for loose change. ¹

Coroner: As coroner I must report, I thoroughly examined her. And she's not only merely dead, she's really most sincerely dead.' ²

Teachable moments come even at 03:12 as I answered a page from the hospital. The resident on the phone reported that they had “coded” a patient three times and the patient kept “coding.” There was no family to “ask about DNR” and the resident inquired how many more times did they need to “code” the patient. My unspoken response was “one more time because three is not enough and five is too many.” Instead, I asked the resident if the patient had a reversible condition causing the continued cardiac arrests and when he said “no,” I told him there was no need to continue resuscitation. “In fact,” I went on “there was no indication for the first attempt if the patient did not have a reversible condition.” I was thanked and he hung up. I hope he gave my rationale to his colleagues on return to the patient room but I fear he may have simply reported “We can stop.”

The euphemistic language that persists in clinician's discussions about cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR) with each other, patients and surrogates, confuses medical decision-making. In the aforementioned patient an advanced cardiac life support (ACLS) code was initiated when the patient was slightly alive. In other circumstances CPR and associated procedures are begun when patients are “all dead” or “most sincerely dead” and the poor outcomes are well known. ³

Coding as a verb is the iconic terminology in the hospital for beginning life-saving efforts, such as fluids, oxygen, and mechanical ventilation, which may continue with the addition of CPR in the face of cardiac arrest. Coding is also used to say that the patient is dying as in, “Get the crash cart, she's coding.” Coded means the patient died or the clinical team performed CPR as in “We coded the MICU patient when she coded.” This doublespeak is highly reminiscent of the “Who's on first?” skit by Abbott and Costello. CPR is a set of procedures that are initiated when a person is dead, in other words, things we do to a dead body. DNR or do not attempt resuscitate (DNAR) is generally meant to describe that CPR will not be initiated when the patient is dead. Unfortunately, clinicians have attempted to use DNR to describe the care the patient will receive when the patient is slightly alive and when the patient is all dead. Code status refers to both the care prior to death, such as intubation, and the procedures or lack of at death. For years we have preached avoidance of jargon when talking to patients; I will take that further and advise against using this jargon when communicating with other clinicians for clarity sake.

In addition to confusing jargon, coupling decisions about treatment goals before death with procedures at time of death confuses clinicians and the patient or patient's surrogates. Uncoupling the discussion about how to care for the patient prior to death from the indications or lack thereof about CPR at death may make more sense to clinicians and patients. I had a conversation about treatment goals with the husband of a frail, elderly lady with advanced Alzheimer's disease. He asked when we would do CPR and I explained that we only use CPR when a patient is dead with a reversible (fixable) illness. He looked puzzled and said, “Why would you do that? Dead is dead”; naturally, I agreed. We were able to move into a discussion of important care decisions about how to care for her until she died.

CPR at death is indicated and saves lives in the cases of witnessed arrest and rapidly reversible illness or injury; very much like the indications suggested in the earliest days of CPR use.^4,5 I propose that instead of discussing DNR we discuss CPR in the same manner we discuss other clinical treatments by describing it as something we do when a patient is dead, who benefits, who does not, and why it is only performed rarely in the hospital. As suggested by Daly, ⁶ it may be time to seek consent for CPR when the patient has an indication and for all other hospitalized patients the default would be to withhold resuscitation. In other words, “with all dead, there's usually only one thing that you can do” offer condolences and help the bereaved.