Choice architecture in code status discussions with terminally ill patients and their families

Cardiopulmonary resuscitation (CPR) was developed to reverse sudden cardiac death due to temporary or reversible insults in previously healthy patients. As with many invasive medical interventions, use spread to less and less healthy patients, to the point at which a universal default arose in most Western nations such that all patients became “full code.” Now, if a heart stops, no matter who’s heart, clinicians try to restart it with chest compressions, shocks, assisted ventilation, and powerful drugs, unless previously and explicitly instructed otherwise.

This full-code default makes sense prima facie: armed with a therapy that might restart a stopped heart, and at a time when every second counts, we should reach for it without delay or deliberation. However, this default has come to include many patients with advanced and often terminal diseases for whom the decision to perform CPR is far more complex. In many patients with terminal diagnoses, CPR is a low-probability attempt at delaying death without affecting the underlying disease process. Some clinicians may recoil at the prospect of providing CPR to terminal patients out of concern for non-maleficence, the ethical principle that we must not inflict harm. Others may be concerned about patient autonomy, questioning whether choices to undergo this procedure in states of advanced illness reflect sufficient comprehension of this widely misunderstood intervention.

These concerns have prompted suggestions that for certain defined populations of patients, the current opt-out approach to CPR be replaced with an opt-in approach, whereby CPR would only be provided if patients or their family members explicitly requested it. We agree with the implication of such proposals that using “nudges” like the switching of default options can have great impact on who receives CPR. However, as we describe in this essay, we believe that top-down approaches in which the default is flipped for prospectively designated categories of patients are inferior to bottom-up approaches whereby clinicians use insights from behavioral economics to change the choice architecture of CPR discussions with individual patients and families.