A patient coded at my hospital without having clear guidelines about what he wanted for treatment plan. It left the hospital staff in a flurry to receive verbal consent from his wife in order to treat him. Bedside ethics are important in cases where decisions about patient care need to be made rapidly. These types of ethical decisions ought not to substitute for clinical ethical discussions with patients about goals of care and lived and stated values. When these conversations do not occur with the patient and the medical team, scrambled decisions about treatment can occur for the patient when the patient is unable to make them. A Code Blue situation is not the time for the medical team to create a new treatment plan for the patient. The medical team ought to know who they are treating before they treat the patient. Pharmacists attend codes at my hospital, and I am certified in Advanced Cardiovascular Life Support (ACLS) so I can be an effective team member. I enjoy being a part of the Code Blue team when called. I participate by preparing medications to administer to the patient and I can help the team save lives with my knowledge and expertise of medications. In addition to a Doctorate in Pharmacy, I have formal training in bioethics as a master’s degree and a fellowship at the Sherwin B. Nuland Center for Bioethics.
One day on my shift, a patient coded on the COVID floor. He had changed his status from “Full Code” to “Do Not Intubate” the night before after having a long conversation with the pulmonologist. The patient had not changed his code status to “Do Not Resuscitate” but only “Do Not Intubate.” The pulmonologist must have focused on the lungs as a focal point when consulting with the patient instead of the whole patient because having “Do Not Intubate” instead of “Do Not Resuscitate” can put the medical team into a difficult situation when the patient codes. The resident physicians were frantically calling the wife of the patient to receive verbal authorization to intubate the patient. As they called the wife, I gathered information about the situation by talking to a resident. I observed the situation without revealing my training in bioethics. The residents were upset that the patient had changed his Code Status the night before after being convinced by the pulmonologist to be “Do Not Intubate.” They wanted to intubate the patient so they could continue to treat him and hopefully send him home to his wife. They cared more about the intervention and the continuation of treatment than the change of the patient’s wishes to meet the patient’s stated goals and values. When the patient was in a state where he did not have decision-making capacity, the residents reached out to his surrogate decision-maker to obtain verbal consent under duress. What if the patient had not informed his wife of the reason why he changed his Code Status the night before? What if she was not privy to any changes he had with his end goals of care? The wife would not be able to truly act as his surrogate decision-maker unless she knew the reason for the change in his Code Status and how that decision aligned with his goals of care.
Saving a life in the hospital is an important responsibility, but before the medical team rushes to treat, we must truly think about the goals and values of the patient. We must stop to consider why the patient changed his Code Status: was he manipulated by the pulmonologist who did not think the patient could survive intubation or was he enlightened of the process of intubation by the pulmonologist and determined on his own that it does not align with his personally held values? Why did he choose to be DNI without being DNR? Code Blue situations can be fast-paced and do not allow ample time to discuss in length the ethical implications of calling the surrogate decision-maker to change code status. But what we do at the bedside during a code matters. Are decisions made based solely on treatment or are lived and stated values of the patient considered? I have seen other situations when the medical team was frustrated that the patient chose to have the “Do Not Intubate” or “Do Not Resuscitate” status because it prevented them from treating. Bedside ethics ought to be thought out and not a hasty reaction to a situation that focuses on action instead of what is best for the patient.
We must remember that treating a patient is not just one task after the next until the patient is discharged or expires. Treating the patient ought to be a holistic activity where every aspect of the patient is considered. Each patient has lived and stated goals and values of their health and how they want to live their lives.
Clinical ethics can illuminate these lived and stated values when discussing treatment plans with patients and their families. When the patient’s desires are not discussed with a clinical ethics care team, unintended consequences can occur such as urgent bedside ethics. These scrambling bedside ethics may not result in the best interest of the patient. An environment of clinical ethics is important to create in the hospital because it leads to knowing who the patient in front of us is and what each patient’s lived and stated values are before we treat them.
As a pharmacist, I understand that medication is not always the best method of helping patients reach their goals. The medical team ought to discuss the lived and stated values of the patient before proceeding with treatment at any cost. I want to help patients reach their lived and stated values instead of focusing only on the treatment. As Code Blue Pharmacists, we may not have the time to discuss the patient’s values at the bedside, but we can pause for one second before we only think about the treatment instead of the patient. We are treating the patient and it is important to know who the patient is before we treat.
Amy Reese, PharmD, MBe is a pharmacist at Hemet Global Medical Center in Hemet, California.