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Resuscitate but not Intubate? Partial Codes in Pediatrics
Andrew Silverman1, Jason Batten2,3, Emily Berkman4,5
1Division of Child Neurology, Department of Neurology.
Insights
Partial code status in pediatric emergencies poses ethical dilemmas. Discussing parental grief, healthcare team distress, and system-level issues is crucial for effective and ethical end-of-life care decisions.
Area of Science:
- Pediatric Medicine
- Bioethics
- Emergency Medicine
Background:
- Partial code status, particularly "resuscitate but do not intubate" orders, presents complex ethical challenges in pediatric critical care.
- A clinical vignette involving a pulseless infant with limited life expectancy highlights these dilemmas.
Purpose of the Study:
- To explore the ethical considerations surrounding partial code status in pediatric medicine.
- To analyze the perspectives of parental grief, healthcare team moral distress, and systems-level factors.
- To propose recommendations for improving hospital policies regarding code status orders.
Main Methods:
- Ethical analysis of a clinical case vignette.
- Commentaries from multiple perspectives: parental grief, healthcare team ethics, and hospital systems.
- Review of existing hospital code status order designs.
Main Results:
- Partial codes can arise from parental grief, but may lead to moral distress for healthcare providers.
- Relational ethics emphasizes honest communication and pain management in these situations.
- Hospital systems may inadvertently encourage partial codes; changes are needed to discourage them.
Conclusions:
- Healthcare systems should discourage partial codes and ensure clarity in resuscitation orders.
- Addressing parental needs while managing healthcare team moral distress requires careful ethical navigation.
- Improved systems design and communication protocols are essential for ethical end-of-life care in pediatrics.
Abstract:
The use of partial code status in pediatric medicine presents clinicians with unique ethical challenges. The clinical vignette describes the presentation of a pulseless infant with a limited life expectancy. The infant's parents instruct the emergency medicine providers to resuscitate but not to intubate. In an emergency, without a clear understanding of parents' goals, complying with their request risks an ineffective resuscitation. The first commentary focuses on parental grief and how, in certain circumstances, a partial code best serves their needs. Its authors argue that providers are sometimes obligated to endure moral distress. The second commentary focuses on the healthcare team's moral distress and highlights the implications of a relational ethics framework for the case. The commentators emphasize the importance of honest communication and pain management. The final commentary explores the systems-level and how the design of hospital code status orders may contribute to requests for partial codes. They argue systems should discourage partial codes and prohibit resuscitation without intubation.
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