Because the heart part is the hard part: an approach for improved advance directive discussions

Advance directives (ADs) delineate an individual’s health care wishes and include a living will (which documents preferences regarding cardiopulmonary resuscitation, or CPR, mechanical ventilation and artificial feeding) and durable power of attorney for health care. Conducting a comprehensive AD discussion properly takes time and should be revisited periodically.

Many individuals, unfortunately, have never had these discussions. Only about 20% of adults have ADs; the majority do not discuss goals of care (GOC) or have end-of-life discussions until they are hospitalized with a serious illness.

Patients with ADs have fewer hospitalizations in their last months of life and are more likely to receive care that aligns with their wishes. However, physicians and other clinicians in outpatient settings have often failed to initiate these discussions for multiple reasons.

Code status — the decision to use CPR — is just one part of ADs, but ascends to one of the highest priorities when an older adult or a patient with an acute or chronic life-threatening illness presents to the emergency room (ER). In a Journal of Emergency Medicine ER study on 187 high-risk patients, or their surrogate decision makers, 84% noted never having previously discussed code status, and 83% were unaware of their current code status. Therefore, unfortunately, many code status discussions take place in the ER.

Were you trained to talk about this?

Code status discussions are challenging, even for oncologists. Physicians’ confidence regarding code status discussions is low compared with their confidence regarding other medical discussions.

It’s often a resident physician who is given the task of the code status discussion prior to admission. In a study published by the Journal of Pain and Symptom Management, 68% of residents surveyed noted not receiving any code status training during medical school, and only 13% felt competent to discuss code status on their first day of residency. A full 75% noted no formal training during residency, and only 39% noted having ever had a code status discussion observed/critiqued by a supervising physician.

But it works so well on TV…

Individuals, family members and caregivers have difficulty with code status discussions for multiple reasons: fear, guilt, distrust of the medical system, spiritual beliefs, etc. They may have misinformation regarding the success of CPR, often due to what has been depicted on television shows.

The New England Journal of Medicine published a review done in 1996 on 96 episodes of “ER,” “Chicago Hope” and “Rescue 911” showed 75% were successfully resuscitated with CPR and 67% of those were discharged from the hospital. Resuscitation published a more recent (2010-2011) review of 91 episodes of “Grey’s Anatomy” and “House” showed a 69.6% success rate of CPR, with 71.9% of those being discharged from the hospital.

The actual success rate of in-hospital CPR is approximately 44%, and only about 17% are ultimately still alive to be discharged from the hospital. Survival to hospital discharge is less than 5% for older adults and those with serious illnesses, according to the Palliative Care Network of Wisconsin. Many who survive have significant neurological and functional impairments.

What should physicians ask patients?

A standard code status question often asked in an ER setting has been: “If your heart stops, do you want us to restart it?”

It’s been equated to a mechanic asking a customer: “If your car stalls, do you want us to jump-start the engine?”

Most say yes to questions such as this, especially in a hospital.

The goal of a code status discussion is to support patient self-determination and, hopefully, avoid nonbeneficial interventions at the end of life. The Palliative Care Network of Wisconsin, offers excellent suggestions on code status discussions. Their “Fast Facts” encompass many optimal principles (open-ended questions, listening to the patient’s story, responding, education, etc.). After reviewing, the following abbreviated approach could be helpful:

First state, “I’d like to talk with you about a health care choice that I review with all patients.”

And then, three questions that could potentially improve the quality of a code status discussion are:

• “What do you understand about your current health situation?”

Transitioning to…

• “What are your health care goals for the future?”

And finally…

• “If you should die despite all our efforts, or in the event of your death, do you want heroic measures to try and bring you back?”

Using the words “die” or “death” helps to clarify that the initiation of CPR is a choice that tries to reverse death.

Continuing the discussion

The discussion can then become more specific, including actual statistics, if/when asked and/or if/when appropriate.

“Deciding not to undergo CPR does not mean that other interventions (medications, antibiotics, fluids, etc.) to treat your current condition are stopped.”

“Roughly, only about 1 out of every 6 (17%) patients who undergo in-hospital CPR survive long enough to be discharged from the hospital.”

Or for an older adult with significant comorbidities:

“Only approximately 1 out of every 20 (5%) older adults, with medical conditions such as yours, who undergo in-hospital CPR will survive long enough to be discharged from the hospital.”

Educational efforts must continue for all health care providers and the public to discuss ADs in a non-ER setting.

Why we must keep talking about this

Television shows are sure to continue to depict favorable outcomes for CPR.

Therefore, discussions often need to be repeated over time as GOC changes (due to changes in one’s medical condition), as well as if/when the outcome information reviewed may be accepted to a greater degree. Hopefully, confidence in these discussions will increase so that, ultimately, the care that is being rendered, especially to older adults with advanced chronic illnesses, will more closely align with their wishes.

William Sheahan, M.D., is a family physician based in Florida who retired after a 40-year medical career. He earned his medical degree at the University of Virginia School of Medicine and, in March 2026, received a foundational certificate in narrative-based medicine from the University of Toronto. He has enjoyed writing on various medical topics over the years. Along with clinical studies and presentations, he is the author of three volumes of “Patients Say the Darndest Things” and “A Doc Who Jots: The more you know about your patient’s story …”