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CME / ABIM MOC

Show Codes, Slow Codes, Full Codes, or No Codes: What Is a Doctor to Do?

  • Authors: Case History by Lois Snyder Sulmasy, JD and Matthew W. DeCamp, MD, PhD; Case Commentary by Matthew W. DeCamp, MD, Diana Jung, MD, Lois Snyder Sulmasy, JD, and Kari L. Esbensen, MD, PhD
  • CME / ABIM MOC Released: 4/25/2023
  • Valid for credit through: 4/25/2024
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  • Credits Available

    Physicians - maximum of 0.50 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.50 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for internists, surgeons, geriatricians, cardiologists, intensivists, oncologists, and other physicians engaged in the care of patients in whom "do not resuscitate" (DNR) and/or "do not intubate" (DNI) orders may be considered.

The goal of this activity is for learners to be better able to describe the implications of "slow" or "show" codes on patient autonomy, the patient-physician relationship, and professional integrity, according to an American College of Physicians Ethics case study and commentary.

Upon completion of this activity, participants will:

  • Describe the implications of “slow” or “show” codes on patient autonomy, according to an American College of Physicians (ACP) ethics case study and commentary
  • Identify the implications of “slow” or “show” codes on the patient-physician relationship, according to an ACP ethics case study and commentary
  • Describe the implications of “slow” or “show” codes on professional integrity, according to an ACP ethics case study and commentary


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


Authors, Case History

  • Lois Snyder Sulmasy, JD

    Director  
    Center for Ethics and Professionalism  
    American College of Physicians  
    Philadelphia, Pennsylvania 

    Disclosures

    Lois Snyder Sulmasy, JD, has no relevant financial relationships.

  • Matthew W. DeCamp, MD, PhD

    University of Colorado Anschutz Medical Campus  
    Associate Professor  
    Department of Medicine  
    Aurora, Colorado

    Disclosures

    Matthew W. DeCamp, MD, PhD, has no relevant financial relationships. 

Authors, Commentary

  • Matthew W. DeCamp, MD, PhD

    As seen above

  • Diana Jung, MD

    Resident   
    Department of Medicine  
    Unity Health-White County Medical Center   
    Searcy, Arkansas 

    Disclosures

    Diana Jung, MD, has no relevant financial relationships. 

  • Lois Snyder Sulmasy, JD

    As seen above

  • Kari L. Esbensen, MD, PhD

    Assistant Professor of Medicine, Senior Faculty Fellow (Emory Center for Ethics)    
    Emory University School of Medicine   
    Atlanta, Georgia

    Disclosures

    Kari L. Esbensen, MD, PhD, has no relevant financial relationships. 

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor

  • Lois Snyder Sulmasy, JD

    Director 
    Center for Ethics and Professionalism 
    American College of Physicians 
    Philadelphia, Pennsylvania

    Disclosures

    Lois Snyder Sulmasy, JD, has no relevant financial relationships. 

Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Ethics case studies are developed by the American College of Physicians Ethics, Professionalism and Human Rights Committee and the ACP Center for Ethics and Professionalism. 

    Medscape, LLC designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.50 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read about the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or print it out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate, but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period, you can print out the tally as well as the certificates from the CME/CE Tracker.

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CME / ABIM MOC

Show Codes, Slow Codes, Full Codes, or No Codes: What Is a Doctor to Do?

Authors: Case History by Lois Snyder Sulmasy, JD and Matthew W. DeCamp, MD, PhD; Case Commentary by Matthew W. DeCamp, MD, Diana Jung, MD, Lois Snyder Sulmasy, JD, and Kari L. Esbensen, MD, PhDFaculty and Disclosures

CME / ABIM MOC Released: 4/25/2023

Valid for credit through: 4/25/2024

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Case History

"Do everything." Ms Smith's family members have been saying this from the start of her latest hospital admission, which started 3 weeks ago after a myocardial infarction. Two years ago, a stroke left Ms Smith, age 89 years, with left-sided hemiplegia but no cognitive impairment. She also has type 2 diabetes and hypertension. Her oldest child, Jean Carey, has been at the hospital every day. She relocated to become her mother's primary caregiver after the sudden death of her father 3 months ago. Before that, Mr Smith had cared for his wife with the assistance of a home health aide.  

Internist Frances Belmont has been caring for Ms Smith for many years, although she had not had much interaction with her children except for meeting Ms Carey at her mother's last office visit. On Ms Smith's admission to the coronary care unit with renal, respiratory, and heart failure, Ms Carey called Dr Belmont trying to get more information. After giving a clinical update, Dr Belmont noted that whenever she tried to have advance care planning discussions with Ms Smith, Ms Smith would respond that her daughter knew her well and "would take care of everything" in the event of a serious illness. Dr Belmont also advised her in the past to speak with her family about her preferences and goals. In fact, Ms Carey is Ms Smith's agent under her durable power of attorney for health care. There are no written instructions in her advance directive. With diminished orientation and alertness, Ms Smith is now unable to participate in conversations about her goals of care and treatment preferences. 

Having lost their father and favorite aunt in the past 6 months, Ms Smith's 3 children are, understandably, distraught. The doctors have been discussing their mom's condition and prognosis at length and have now broached the topic of a do-not-resuscitate (DNR) order for Ms Smith, but the family members are very opposed and want "everything possible" to be done. Ms Carey has left a message for Dr Belmont asking for advice.  

Dr Belmont thinks a DNR order is appropriate and is contemplating how events might unfold without a DNR order. She fears that the treatment team may resort to a "show" code for the family. She is concerned for the family but feels strongly the primary obligation is to the patient. A colleague she consults with also questions the use of a code team in such a case, but another colleague asks, "Wouldn't it demonstrate caring to the family and acknowledge their grief? And just be easier?"

How should Dr Belmont discuss the DNR order and its implications with Ms Smith's daughter when she calls her back?

Table of Contents

  1. Case History
  2. Commentary
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