Levels of Intervention for Resuscitation and Other Critical Interventions
Executive Summary
Description:
This policy replaces policy R4.1 entitled “Resuscitations and Other Critical Interventions (1999)”. It describes five possible levels of intervention that can be assigned to a patient in order to assist the healthcare team with decisions regarding to the use of potentially life-sustaining interventions (resuscitation and other critical interventions). The policy also provides background information regarding the guiding principles of ethics on which such decisions should be based. Guidelines regarding how to discuss critical interventions and deal with potential conflicts regarding these decisions are also presented. The roles of all members of the healthcare team are defined and the procedure for documenting these discussions and decisions is described.
Major Changes from the Former Policy:
Previously, patients were assigned a status of “Full Code” or “No Code”, with the option of specifying specific interventions that would or would not be performed. The current policy describes five possible levels of intervention. A “Code Blue” is to be called when appropriate for patients designated Level I, IIa or IIb, but not for patients designated level III or IV. The policy now includes a Level of Intervention Order Sheet which is to be the mechanism for ordering and documenting the level of intervention. Clearer guidelines address how to discuss critical interventions with patients/families and ways to manage conflicts should any arise.
Description of the Levels of Intervention:
Level 1: Provision of maximal interventions offered by the treating team (including chest compressions and critical care unit transfer.) All patients are assumed to be Level 1, unless medical reasons or patient preference suggest otherwise.
Level 2A: Provision of maximal interventions with some restrictions. Chest compressions are to be initiated in the event of cardiopulmonary arrest. Other restrictions must be specified (for example, intubation, mechanical ventilation, etc.). Restrictions can relate to specific situations or procedures.
Level 2B: Provision of maximal interventions with some restrictions, as described in Level 2A. In the event of cardiopulmonary arrest, however, chest compressions are NOT to be initiated.
Level 3: Provision of maximal interventions on the ward aimed at treating reversible conditions, maintenance of function and comfort care, but no chest compressions and no transfer to a critical care unit. Any additional restrictions must be identified (for example, dialysis, surgery).
Level 4: Provision of interventions adapted to palliation and patient comfort. The primary goal of care is comfort and dignity. This includes relieving lessening symptoms without achieving cure, and can include treating some reversible conditions. No chest compressions. No transfer to a critical care unit. Instructions regarding treatment of reversible conditions must be specified.