“Do-Not-Resuscitate” to “Goals of Care” policies

© 2018 Annals of Thoracic Medicine | Published by Wolters Kluwer – Medknow 67
Shifting paradigm: From “No Code”
and “Do-Not-Resuscitate” to “Goals of
Care” policies
Yaseen M. Arabi1,2, Abdulla A. Al-Sayyari3,4, Mohamed S. Al Moamary4
Policies addressing limitations of medical therapy in patients with advanced medical conditions are
typically referred to as Code Status (No Code) policies or Do-Not-Resuscitate (DNR) status polices.
Inconsistencies in implementation, understanding, decision-making, communication and management
of No Code or DNR orders have led to delivery of poorer care to some patients. Several experts
have called for a change in the current approach. The new approach, Goals of Care paradigm, aims
to contextualize the decisions about resuscitation and advanced life support within the overall plan
of care, focusing on choices of treatments to be given rather than specifically on treatments not to
be given. Adopting “Goals of Care” paradigm is a big step forward on the journey for optimizing the
care for patients with advanced medical conditions; a journey that requires collaborative approach
and is of high importance for patients, community and healthcare systems.
Cardiopulmonary resuscitation, critical care, decision-making, palliative care, patient comfort
Policies addressing limitations of medical
therapy in patients with advanced
medical conditions are integral components
of clinical practice worldwide and are
mandated by hospital accreditation
agencies.[1,2] These policies often focus
on decisions regarding resuscitation and
advanced life support and are typically
referred to as Code Status (No Code)
policies or Do-Not-Resuscitate (DNR) status
polices. These policies have been important
tools in recognizing the limited value of
aggressive life support in patients with
advanced medical conditions. Studies have
shown that around 80%–90% of patients
who die in the hospital have DNR orders.
[3,4] In Saudi Arabia, several hospitals have
adopted “No Code” or DNR polices based
on related Fatwa,[5] on Code of Ethics for
Healthcare Practitioners by the Saudi
Commission for Health Specialties,[6] and
on the newly released National Policy And
Procedure For DNR Status by the Saudi
Health Council.[7] Similar to other countries,
studies from hospitals with established
policies in Saudi Arabia demonstrated that
DNR orders were written for 66% and 84%
of patients who eventually die in Intensive
Care Units and wards, respectively.[8]
However, inconsistencies in implementation,
understanding, decision-m a k i n g ,
communication, and management of No
Code or DNR orders have led to delivery of
poorer care to some patients.
In this article, we present reasons why a
paradigm shift is needed in the approach to
addressing limitations of medical therapy in
patients with advanced medical conditions
in Saudi Arabia and present a suggested
model based on international and local
Why Change is Needed?
Challenges of the approach of Code Status
or DNR have been increasingly recognized,
Department of Intensive
Care, 2
King Abdullah
International Medical
Research Center, College
of Medicine, King Saud
Bin Abdulaziz University
for Health Sciences, King
Abdulaziz Medical City,
Division of Nephrology
and Renal Transplantation,
Department of Medicine,
College of Medicine,
King Saud Bin Abdulaziz
University for Health
Sciences, King Abdulaziz
Medical City, Riyadh,
Saudi Arabia
Access this article online
Quick Response Code:
How to cite this article: Arabi YM, Al-Sayyari AA,
Al Moamary MS. Shifting paradigm: From “No Code”
and “Do-Not-Resuscitate” to “Goals of Care” policies.
Ann Thorac Med 2018;13:67-71.
Address for
Dr. Yaseen M. Arabi,
Chairman, Intensive Care
Department, MC 1425,
Professor, College of
Medicine, King Saud Bin
Abdulaziz University for
Health Sciences, King
Abdullah International
Medical Research Center,
P.O. Box 22490, Riyadh
11426, Kingdom of Saudi
E-mail: [email protected]
Submission: 25‑12‑2017
Accepted: 01‑01‑2018
This is an open access journal, and articles are distributed under
the terms of the Creative Commons Attribution-NonCommercialShareAlike 4.0 License, which allows others to remix, tweak, and
build upon the work non-commercially, as long as appropriate
credit is given and the new creations are licensed under the
identical terms.
For reprints contact: [email protected]
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Arabi, et al.: No Code or Goals of Care
68 Annals of Thoracic Medicine ‑ Volume 13, Issue 2, April-June 2018
not only in Saudi Arabia but also worldwide.
1. Inconsistencies in implementation of the concept of No
Code or DNR; for example, many hospitals in Saudi Arabia
do not have such policies
2. Inconsistencies in understanding the concept of No Code
or DNR: Many practitioners, patients, and families still
have uncertainties about the concept of No Code or DNR.
A survey of interns and residents in four major hospitals in
Jeddah demonstrated lack of familiarity with DNR policies
and limited understanding when it comes to treating
DNR-labeled patients[9]
3. Inconsistencies in the decision-making of No Code
or DNR: The involvement of patients and families in
the decision-making process can be limited with the
predominance of physician-based approach in the
decision-making process.[9] There are also ethical concerns
about the inadequate ways that DNR decisions are made
and how they are communicated to patients or their
families.[10] Furthermore, patients’ dignity, religious
concerns, and emotional support aspects are not sufficiently
addressed in many existing policies
4. Inconsistencies in communication of No Code or DNR
discussions: It has been noted that the conventional
approach of DNR policies may not lead to accurate
mutual comprehension between clinicians and patients
and to the total and necessary grasp of the latter about the
concept of DNR.[11] It is our experience that the “negative”
terminology implied by the terms “No Code” or DNR is
often perceived by patients and families with suspicion
and alarm. The focus of discussion related to Code Status
is often isolated from the larger and the obligatory, in our
view, context of a patient’s plan of care.[11] Due to these
difficulties, such conversations may never occur or occur
too late[12,13]
5. Inconsistencies in the management of No Code or DNR
orders: There is a common false belief among health-care
professionals that a “No Code” or “DNR” order always
means that the patient is approaching end of life and that
it means that other treatments should be withheld, yet
reports from the United Kingdom showed that as much
as 50% of inpatients labeled as “No Code” leave hospital
to home. Studies have shown that inpatients with
“No Code” or DNR status may receive less adequate
treatment and have higher mortality than patients
without this status.[14-18]
A Proposed Model: Goals of Care
Given these concerns, several experts have called for a
change in the current approach.[4] The new approach,
Goals of Care paradigm, aims to contextualize the
decisions about resuscitation and advanced life support
within the overall plan of care, focusing on choices
of treatments to be given rather than specifically
on treatments not to be given (e.g., withholding
cardiopulmonary resuscitation).[4,11] The differences
between the traditional approach and Goals of Care
model are summarized in Table 1.
The “Goals of Care” paradigm has been designed as
a replacement for “No Code” or DNR orders. This
approach has been used in several countries, including
the USA, Canada, the United Kingdom, and Australia.[19]
Recently, the Ministry of National Guard Health Affairs,
Saudi Arabia, has revised the existing “No Code” policy
to be replaced by “Goals of Care Determination” policy
to reflect this new broader approach. If the patient’s
assessment of likely treatment outcomes suggests the
need to have limitations of the levels of care, clinicians
determine a patient’s situation to one of the two levels
of “Goals of Care” instead of “No Code” status as has
Table 1: Comparison between the traditional model of No Code or Do-Not-Resuscitate (DNR) and the Goals of
Care models
No Code or DNR Goals of Care
Breadth of the concept Narrow approach, focusing on resuscitation or life
support at very advanced stage
Broader approach focusing on establishing an overall
plan of care
Terminology Negative implication of “No” and “Do Not” Positive implication of “Goals of Care” “Care” “Support”
Focus What is not going to be provided What is going to be provided
Perception of families Occasionally perceived negatively More likely to be perceived positively
Perception of health-care
Occasionally misunderstood as less care Clear focus on providing care
Engagement of different
Typically, single-discipline focus Multidisciplinary approach: medical, nursing, social
services, patient relations, spiritual support, and ethics
Emotional support Emotional support is typically mentioned, but not a
major focus of the policy
Major emphasis on emotional support for patients and
Practical implications Patients and families often do not accept the concept
Physicians may not be comfortable with discussing
the idea with patients and families
Many hospitals do not have established policies
Lack of or delays in addressing end-of-life care
Inappropriate and futile care provided for many
Better acceptance by patients and families
More willingness to address by physicians
This may translate to earlier approach to end-of-life care
More appropriate care provided to match the clinical and
emotional need of patients and families
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Arabi, et al.: No Code or Goals of Care
Annals of Thoracic Medicine ‑ Volume 13, Issue 2, April-June 2018 69
been the case before; these are either “Support Care” or
“Comfort Care” levels.
Support Care, in our model, refers to the level of care
in which all types of medical therapy that are normally
provided to patients on hospital wards are maintained.
This includes physician visits, vital sign monitoring,
oxygen, intravenous fluids, nutrition, nursing care,
antibiotics, deep vein thrombosis prophylaxis, and
respiratory care (suctioning, chest physiotherapy,
bronchodilators, etc.). Selected oncology patients can
receive palliative anticancer therapy. However, the
following therapies are not provided: cardiopulmonary
resuscitation including chest compressions, endotracheal
intubation, mechanical ventilation, initiation of
vasopressor therapy, initiation of renal replacement
therapy, admission to an Intensive Care Unit, and major
surgical interventions.
For those patients who are already in a critical care
area and show no response to aggressive life support
interventions, Support Care refers to the level of
care in which there is no escalation of life support
measures while continuing those measures already
applied. Patients with Support Care status who require
palliative procedures (i.e., percutaneous endoscopic
gastrostomy tube insertion and tracheostomy) can be
taken to the operating room. However, major surgical
or invasive procedures that are unlikely to change the
patient’s outcome may not be performed in Support
Care patients.
Comfort Care refers to the level of care in which
treatments aiming at symptom relief are provided but
not disease-targeted therapies. Patients in this group will
have physician visitation and nursing care. In addition,
nutritional and feeding support will continue. Patients
must receive appropriate measures that reduce suffering,
pain, thirst, dyspnea, etc., However, other aspects of
disease-targeted therapy may not be continued.
Goals of Care policies should emphasize that appropriate
measures are taken and monitored to ensure the comfort
and dignity of patients at all times. Efforts must be
made to reduce patient pain and symptoms. Visiting
hours should preferably be extended for immediate
family members. Support Care or Comfort Care must
not lead to a reduction in the level of communication
with the patient and family, but must lead to more
support including regular patient assessment and active
communication with the patient and family.
The Goals of Care paradigm emphasizes the
multidisciplinary approach that requires the involvement
of all health-care providers. Table 2 provides an outline of
involvement of different disciplines in the management
Table 2: Multidisciplinary involvement in managing
limitations of medical therapy in patients with
advanced medical conditions
Disciplines Recommendations
Have a policy for Goals of Care
Emphasize that addressing Goals of Care is
part of clinical responsibility of physicians
Have a system for training on Goals of Care
Physician Coordinate multidisciplinary meetings to
assess the physical, psychological, social,
spiritual, ethical, and cultural needs of the
patients and families
Discuss Goals of Care with honesty,
sensitivity, and compassion and use simple,
clear but accurate language to express the
Nurses Act as patient advocate
Ensure that patient daily care is maintained
including basic care requirements (mouth
care, eye care, positioning, pain assessment,
and intervention)
Participate in all multidisciplinary team
meetings involving patients and families
Social services
and patient
Provide emotional support to patients and
families and ensure their understanding of the
Goals of Care
Provide daily follow-up as required
Arrange and attend multidisciplinary meetings
Provide educational material on Support Care
or Comfort Care
Review referrals when there is a conflict
regarding Goals of Care determination as
requested by the most responsible physician
and provide a resolution to any conflict
The palliative
care team
Participate in the training of health-care
professionals in relation to communication
skills, discussing goals of care and breaking
difficult news
Assist the primary treating team in the
management and discussion of Goals of Care
The spiritual
Assess spiritual needs for terminally ill
Provide spiritual support and counseling in
agreement with the wishes and requirements
of the patient/family
Coordinate with other health-care
professionals to assist in resolving
spiritual/ethical issues
Provide bereavement support to patient and
staff when required
of patients with Support Care or Comfort Care. Support
Care and Comfort Care status determination should
activate referral to social services and patient relations
for implementation of regular structured follow-up,
support, and communication with the family.
Applicability in Saudi Arabia
Using Goals of Care to guide decision-making about
medical therapy in patients with advanced medical
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Arabi, et al.: No Code or Goals of Care
70 Annals of Thoracic Medicine ‑ Volume 13, Issue 2, April-June 2018
conditions is expected to enhance the quality of patient
care by addressing the aspects of medical care and
emotional support as part of a broader global care plan.
This would likely alleviate the uncertainties of patients
and families regarding decisions that involve limitations
of medical care and may reduce refusals and delays
in the process. Studies from Saudi Arabia comparing
this newly introduced approach with the traditional
No Code or DNR approach are needed. A randomized
vignette study from the UK compared the approach of
DNR orders and Goals of Care approach (also called the
Universal Form of Treatment Options [UFTO]) on nurses’
decision-making about a deteriorating patient.[20] Nurses
in the DNR group agreed or strongly agreed to initiate
fewer intense nursing interventions than the UFTO and
no-form groups (P < 0.001), including decisions related
to monitoring, escalation of concerns, and initiation of
treatments (all P < 0.001).[20] On the other hand, there was
no difference between the UFTO and no-form groups
overall (P = 0.78) or in any of the individual decisions.
The study concluded that DNR approach, but not the
UFTO approach, appeared to negatively influence nurses’
decision-making in a deteriorating patient vignette.
Based on these findings, the authors recommended that
hospitals adopt the Goals of Care approach.[20]
The Way Forward
Adoption of Goals of Care concept nationally may
address the current challenges in discussions regarding
limitations of medical therapy for patients with advanced
medical conditions. In addition, it may help bridging
the gap in understanding among health-care providers
regarding this important issue in Saudi Arabia. Table 3
summarizes high-level recommendations for future
directions in addressing Goals of Care with selected
references included as examples of similar initiatives.
Of particular importance is having structured training to
practicing professionals as well as in-training residents.
In addition, there is a need for building capacity in
training skills of communicating bad news and in
incorporating palliative care services across different
We believe that adopting “Goals of Care” paradigm is
a big step forward on the journey for optimizing the
care for patients with advanced medical conditions;
a journey that requires collaborative approach and is
of high importance for our patients, community, and
health-care systems.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Table 3: Selected high-level recommendations for
future directions in addressing Goals of Care. Some
references are included as examples of similar
Domain Recommendations
Review current practices and further develop
current national standards
Establish quality improvement initiatives
and quality indicators to measure the
appropriateness and timeliness of Goals of
Research Develop research agenda to address issues
related to limitations of medical therapy in
patients with advanced medical conditions[22]
Prioritize research in this field when establishing
clinical research funding
Community Engage the medical, Islamic, legal, and
community at large in discussions reading the
limitations of medical therapy in patients with
advanced medical conditions
Explore the applicability of other approaches,
such as advanced directives[23]
Training Establish standard competencies for practicing
physicians, nurses, and other health-care
professionals regarding communication skills in
relation to Goals of Care discussion[24]
Incorporate the concepts of limitations of
medical therapy in patients with advanced
medical conditions in the curricula of
undergraduate medical and nursing education
1. Joint Commission International Accreditation Standards for
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3. Aune S, Herlitz J, BÃ¥ng A. Characteristics of patients who die
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9. Amoudi AS, Albar MH, Bokhari AM, Yahya SH, Merdad AA.
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