When I was working on the inpatient wards and medicine consult service at Maastricht University Medical Center in The Netherlands, the day usually started with “running the list” during table rounds. Frequently, an attending physician would check with the house staff or medical student presenting for the middle-old (74-84 years old) and oldest-old (85+ years old) patients because the individual is hospitalized for a serious acute illness, “their life expectancy is only another [X months or Y years].” I noticed this comment recurred in situations when weighing the benefits or risks of medications, such as acenocoumarol (coumadin), statins, or certain antihypertensives. What is the expected added benefit of the medication for this patient versus the potential risks (e.g., of bleeding, falls)? What mental calculator and evidence basis is the foundation for these considerations? How accurately does this mental calculator predict the possible outcomes, including death?
Talking about life expectancy is a shifted perspective, compared to talking about code status. Life expectancy seems to take on a more holistic perspective of the patient’s health status and considers the complexity of their medical and social circumstances—something we pride ourselves in being primely positioned to accomplish as general internal medicine physicians. When I was in residency training, I often encountered a different question for hospitalized patients: what is the patient’s code status? Informed by best evidence in geriatrics care, a conversation around life expectancy as a way to drive medical or shared decision making was far less common.
Code status is still a vital piece of information for hospitalized patients during my work in a Dutch hospital. For almost every elderly patient admitted, especially those with multiple medical conditions—possibly with or without a dementia diagnosis or delirium—they always had their resuscitation status documented. I noticed a stark difference with the United States hospital system: If their code (or resuscitation) status could not be confirmed by the patient or a family member, Dutch physicians would indicate that a patient’s status is “NRNB (niet reanimatie niet beademing) op medische grond.” This translates most closely to “DNR/DNI on medical grounds.” This is remarkable and worth additional consideration. The doctor asserts their medical judgment to indicate that a patient is not to be resuscitated and not to be intubated. Furthermore, this can be considered a standard practice. Of course, the ideal scenario is still to be able to confirm with the patient, a spouse, or next closest kin or surrogate decision-maker as soon as possible. But what this means is that if an unexpected demise of a patient occurs in the hospital, despite best efforts to diagnose and treat the patient, just short of resuscitation and intubation, this could be medically acceptable.
The Dutch health system and policies can be quite different compared to the U.S. health system. To name a few distinctions, there is a very strong gatekeeper system through general practitioners, a system for patient complaints and malpractice is also completely different and far less litigious, and of course, a long-established medical end-of-life or euthanasia policy.1
Nevertheless, the ability to be able to indicate resuscitation status “on medical grounds” still surprised my acculturated American medical senses. As a comparison, I remember from residency encountering a case of a 101-year-old woman with a hip fracture and delirium admitted to my inpatient hospital service. While I no longer remember the full case details, I recalled how she experienced a code before a family member could be contacted to verify code status and was resuscitated and intubated, as a default. I also remember that once a family member was reached, that family member still wanted their mother’s chart to indicate “Full Code.” There are numerous ethical questions raised in this situation, which I will not explore in this column, although additional debate is welcome from SGIM colleagues in future SGIM Forum publications. I expect that a comparable case encountered in a Dutch hospital might have had a different outcome, based on my limited experiences in the system.
Stepping back from the reductive “code status” conversation and returning to engaging in hospital-based decision making partially by life expectancy, I appreciate the different perspective that this mindset could help to frame some decisions that we face in routine patient care. Some decisions are straightforward. On the other hand, they can be complex—sometimes, it can be useful to step back and try a different approach. Accounting for life expectancy might be one potential additional consideration in the big picture of taking care of a patient across care settings and engaging in shared decision making.
Acknowledgements: I wrote the original version of this column during the 2021 edition of the Hospital Medicine Writing Challenge.2
- Statistics Netherlands. End-of- life care often involves pain or management. https://www.cbs.nl/en-gb/news/2023/22/end-of-life-care-often-involves-pain-or-symptom-management. Published June 8, 2023. Accessed September 15, 2023.
- Keniston A, Frank M, McBeth L, et al. Utilization of a national writing challenge to promote scholarly work: A pilot study. Cureus. 2022;14(2):e21935. Published 2022 Feb 5. doi:10.7759/cureus.21935.
Clinical Practice, Geriatrics/Palliative Care, Medical Ethics, SGIM
Dr. Leung (email@example.com) is a telemedicine physician, adjunct clinical associate professor at Southern Illinois University School of Medicine in Springfield, Illinois, and scientific editorial director at JMIR Publications in Toronto, Canada.
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