Code status is not goals of care:
the conversations, untangled
Interns learn these words as one blur — code status, goals of care, DNR, advance directive, POLST, hospice — and the blur produces the classic July errors: the code-status question asked as a checkbox, the DNR misread as do-not-treat, the surrogate guessed instead of identified. This session pulls the concepts apart, then rehearses the one conversation every intern owns from night one: code status on admission, done as medicine rather than paperwork.
What interns leave able to do
- Define and separate the concepts: code status · goals of care · advance directive · POLST-type orders · surrogate decision-making · comfort-focused care · hospice — related, never interchangeable.
- Run the admission code-status conversation: context first, values before interventions, a recommendation when appropriate, and documentation that matches what was said.
- Identify the legal decision-maker correctly — capacity assessed for this decision, the documented surrogate found, the hierarchy looked up rather than assumed.
- Say what DNR does and does not change — and catch the do-not-treat error in themselves and others.
- Know the intern’s role at a death: who examines, who pronounces under local policy, who calls whom, and what the family hears first (the hospital-machine session carries the full sequence).
The case
11 p.m., your fourth admission: an 82-year-old man with pneumonia and moderate dementia, accompanied by his daughter. Your senior says “get the code status.” At the bedside you hear yourself ask: “If your heart stopped, would you want us to do everything?” He looks at his daughter. She looks at you. “What kind of question is that? Of course we want everything.”
What went wrong in that sentence — every part of it — and how should this conversation actually start?
You look deeper: the chart holds a living will from 2015 (“no prolonged artificial life support”), a POLST-type form from last year marked DNR, and tonight’s ED note: “full code per family.” His dementia means his capacity for this decision is genuinely uncertain.
Which document governs tonight, who decides, and what — exactly — do you do before you write any order?
Teaching points
- The taxonomy, on the board: code status is an order about one moment — arrest; goals of care is the larger conversation about what treatment should accomplish; an advance directive is the patient’s prior written voice; a POLST-type form is a portable medical order; a surrogate speaks when the patient cannot; comfort-focused care and hospice are care models, not death sentences. A patient can be DNR and want aggressive pneumonia treatment; the combinations are the point.
- Context before question: the conversation starts with what is wrong and what treatment can do — then what matters to the patient — and only then interventions. “Would you want everything?” is not a question; it is an accusation wearing one’s clothes. The serious-news skills (the serious-news session) are the same skills at lower volume.
- Values, then a recommendation: when the picture supports one, a clinician recommends — “based on what you’ve told me matters to him, I’d recommend…” — because handing a menu to a frightened family is abandonment dressed as autonomy. The attending owns the hard versions; the intern learns by being in the room.
- DNR changes one thing: what happens at arrest. Everything else — antibiotics, the ICU when appropriate, surgery, comfort — follows the goals of care. The do-not-treat misread harms patients quietly and often; name it so interns police it.
- The decision-maker is found, not guessed: capacity is decision-specific and assessed; the documented surrogate or healthcare agent is identified from the chart; the default hierarchy when nothing is documented is state law — look it up (the state-law worksheet holds the slot). Conflicting documents get resolved with the attending tonight, not inherited by the day team.
- The conversation happens in the patient’s language: a qualified interpreter for any language barrier — this conversation is the last place to improvise access (the interpreter session carries the rules) — and it closes with teach-back, because “DNR” misheard is a harm all its own.
- Documentation is the conversation’s twin: the order, the note stating who was present and what was decided, and the handoff line — a code-status conversation that lives only in memory did not happen.
Running the room
| Minutes | Block |
|---|---|
| 0–10 | The taxonomy on the board, built from the room’s own definitions — let the blur show first |
| 10–25 | Part 1 — run the bedside moment twice: once as the checkbox version, once done well; the room names every difference |
| 25–40 | Part 2 — the three-document conflict: who decides, what happens before any order |
| 40–65 | Paired rehearsal of the admission conversation, observers scoring three behaviors: context before question · values before interventions · a recommendation offered |
| 65–75 | The intern’s role at a death, briefly · pocket card |
Watch for, and debrief by name: the menu recitation — interventions listed like a waiter (“compressions, shock, breathing tube…?”) before any context; the “would you want everything?” relapse under time pressure; outcome promises (“CPR would work / wouldn’t work”) in place of honest uncertainty; and DNR quietly expanding into do-not-treat in the room’s own language — catch it live, because that is exactly how it happens on the wards. Expected Part 2 commitments range from “follow the POLST” to “full code until sorted”; the teaching point is that tonight’s attending call and the documented resolution are the answer, not either reflex.
Pocket card
- Code status ≠ goals of care. DNR ≠ do not treat. Hospice ≠ giving up.
- Context → values → recommendation → order. Never lead with the checkbox.
- Capacity is decision-specific. Surrogates are found in the chart and the law, not assumed at the bedside.
- Conflicting documents = attending tonight, resolved before the order.
- Document who, what, and the order — and hand it off out loud.
Notes
Palliative-care faculty lead; rehearse Part 1 twice — once as the checkbox version, once done well — because hearing the difference teaches more than describing it. The case is a fictional composite. Surrogate hierarchies, pronouncement rules, and POLST equivalents are state and institutional matters — localize before teaching.
This page is a teaching framework for facilitated small-group education, not clinical or legal guidance. Last reviewed July 2026.