Code Status Discussion Note: Documenting Goals of Care

Introduction: Clarifying Life-and-Death Decisions

The Code Status Discussion is one of the most consequential conversations in medicine. It translates a patient’s values into concrete medical orders—specifically regarding cardiopulmonary resuscitation (CPR) and intubation. A clear, well-documented note prevents trauma, confusion, and unwanted interventions during a crisis.

Why a Standardized Note is Essential

Ambiguity in code status can lead to ethical disasters. A structured template ensures:

• Patient Autonomy: It records exactly what the patient defined as a "meaningful life" (e.g., "I do not want to live on a machine").
• Legal Protection: It documents *who* made the decision (patient vs. surrogate) and that informed consent was obtained regarding the risks of CPR (broken ribs, brain damage).
• Team Clarity: In a cardiac arrest code, the team needs to know instantly: "Are we intubating?" Indecision costs lives.
• Family Peace: It serves as a record that the family's difficult decision was based on medical advice and the patient's own wishes.

Key Components of a Goals of Care Note

A defensible note must capture more than just a checkbox. It should include:

• Capacity Assessment: Statement that the patient was alert, oriented, and capable of making complex medical decisions.
• Participants: Who was in the room? (Spouse, children, interpreter).
• Understanding of Prognosis: Does the patient understand they have a terminal condition?
• Values & Fears: "Patient states their biggest fear is being a burden" or "Patient wants to live long enough to see grandson born."
• Specific Orders: Explicit "Yes/No" for CPR, Defibrillation, Intubation, and Artificial Nutrition.

Complete Code Status Discussion Template

GOALS OF CARE / CODE STATUS DISCUSSION NOTE

Date/Time: [Date] | Provider: [Name, MD/DO]
Patient: [Name] | MRN: [Number]
Participants: Patient, [Spouse Name], [Daughter Name].

1. Indication for Discussion:
Admission for acute respiratory failure in setting of advanced COPD and metastatic lung cancer.

2. Assessment of Capacity:
Patient is alert and oriented x3. Demonstrates understanding of current condition, prognosis, and the risks/benefits of proposed interventions. Capable of medical decision making.

3. Understanding of Illness:
Patient understands that his lung cancer is incurable and that his breathing tests show severe decline. He acknowledges that admission to the ICU would likely result in permanent ventilator dependence.

4. Values and Goals:
Patient states: "I have fought hard, but I am tired. I do not want to spend my last days sedated in a hospital bed with tubes."
Priority: Comfort, being able to communicate with family, avoiding pain.

5. Discussion of Interventions:
*   CPR: Explained that in his condition, success rate is <5% and risk of rib fracture/trauma is high. Patient DECLINES.
*   Intubation: Explained that he would likely not be weanable from the vent. Patient DECLINES.
*   NIV (BiPAP): Discussed as a bridge to comfort or recovery. Patient ACCEPTS for a time-limited trial of 48 hours.

6. Final Code Status Orders:
*   DNR (Do Not Resuscitate)
*   DNI (Do Not Intubate)
*   Comfort Measures Always (CMA)

7. Plan:
Current orders updated in EHR. POLST form signed by patient and physician today and placed in chart. Palliative care consult placed to assist with symptom management.

Physician Signature:
_________________________

Automating Sensitive Documentation with HealOS

Capturing the nuance of these conversations is vital. HealOS AI agents allow you to focus on the patient, not the computer:

• AI Medical Scribe: Silently transcribes the family meeting, accurately capturing direct quotes about the patient's wishes and fears without interrupting the flow of the conversation.
• Patient Data Management Agent: Instantly retrieves past Advance Directives or POLST forms from external health exchanges, ensuring the team knows the patient's history *before* walking into the room.
• Clinical Documentation Agent: Automatically drafts the formal "Code Status Note" from the transcript, verifying that all legal requirements (capacity statement, specific exclusions) are documented.

Automated Workflow Diagram (Mermaid)

graph TD
    A[Admission/Change in Status] --> B[HealOS Agent Checks for Existing POLST];
    B --> C[Provider Initiates Goals of Care Meeting];
    C --> D[HealOS Scribe RECORDS Discussion];
    D --> E[HealOS Drafts Note with Quotes & Orders];
    E --> F[Provider Signs & Finalizes];
    F --> G[Code Status Orders Updated in EHR];
    G --> H[HealOS Flags 'DNR' on Patient Dashboard];

Frequently Asked Questions (FAQs)

Respecting Wishes Through Clarity

End-of-life care should be driven by the patient's values, not confusion. Use HealOS to ensure that every patient's voice is heard, documented, and honored.

Explore HealOS Agents

Example Code Status Note