Cause Someday We All Die”

“Code status” is a prominent feature of end-of-life discussions in U.S. hospitals. This essay analyzes how the rhetoric of code status articulates the terms of end-of-life decision-making in one hospital's “Patient” Preferences Worksheet. The Worksheet signifies the abandonment of the technological fix as the preferred treatment for moribund patients and the transformation of a previously private moment into a matter of institutional control. Examining the Worksheet's interlocking institutional, technical, and vernacular deathbed rhetoric challenges the dominant bioethical discourse of patient autonomy and suggests a need to supplement this procedurally rational discourse with one of relational integrity. Notes 1. Lloyd F. Bitzer, “The Rhetorical Situation,” Philosophy and Rhetoric 1 (1968): 1–14. In the 39 years since Bitzer's essay, the U.S. experience of death and dying has undergone radical transformation. Technological developments have, on the one hand, allowed unprecedented possibilities for sustaining physiological life, while bureaucratization and a growing patient autonomy movement, on the other, have shifted the locus of medical decision-making away from physicians towards patients and their proxy decision-makers. Even the definition of death itself is contested, with various standards of brain death producing different estimations of whether a person is really “dead.” For a discussion of these standards, see Amir Halevy and Baruch Brody, “Brain Death: Reconciling Definitions, Criteria, and Tests,” Annals of Internal Medicine 119 (1993): 519–25. Edward Schiappa includes a rhetorical treatment of definitions of death in Defining Reality: Definitions and the Politics of Meaning (Carbondale: Southern Illinois University Press, 2003). 2. Readers should note that throughout this essay, I hyphenate the adjectival phrase “end-of-life,” but not the noun phrase “end of life,” unless I am preserving another author's original punctuation in a citation. 3. Ferdinando L Mirarchi, What's the Patient's Code Status? A Patient and Family Guide to the Components of Advance Directives and Code Status Designation (Erie, PA: Patient Advanced Educational Resource, 2000), 20. Betty Calum, Susan Far, and Rodney Andrew treat “code status” as synonymous with “resuscitation preferences” in “Discussions of ‘Code Status’ on a Family Practice Teaching Ward: What Barriers Do Physicians Face?,” Canadian Medical Association Journal 163 (2000): 1255–59. In the structured group interviews I moderated with first- and third-year medical residents in the winter and spring of 2003, the term was often treated synonymously with any end-of-life treatment intervention. 4. In Re Quinlan, 355 A.2d 647 (1976), the court held that life support can be terminated from patients in persistent vegetative states if ethics committees confirm prognosis. In Cruzan v. Director, Missouri Department of Health, 497 U.S. 261, 278 (1990), the court ruled that competent persons have a constitutionally protected liberty to refuse unwanted medical treatment. 5. Jay A. Jacobson and Evelyn Kasworm, “May I Take Your Order: A User-Friendly Resuscitation Status and Medical Treatment Plan Form,” Quality Management in Health Care 7, no. 4 (1999): 13–20; Vera A. DePalo, Rhonda Iacobucci, and Robert S. Crausman, “Do-Not-Resuscitate and Stratification-of-Care Forms in Rhode Island,” American Journal of Critical Care 12 (2003): 239–41; Andrew J. Ravenscroft and M. D. Dominic Bell, “‘End-of-life’ Decision Making within Intensive Care—Objective, Consistent, Defensible?,” Journal of Medical Ethics 26 (2000): 435–40; Robert M. Veatch, “Do-Not-Resuscitate: Ordering Nonassault and Charting Patient's Decisions to Forgo Cardiopulmonary Resuscitation,” Critical Care Medicine 31 (2003): 1593–95; and Donna M. Wilson, “Highlighting the Role of Policy in Nursing Practice through a Comparison of ‘DNR’ Policy Influences and ‘No CPR’ Decision Influences,” Nursing Outlook 44 (1996): 272–79. 6. To protect the identity of the hospital, “Good Care Hospital” is a pseudonym. 7. The Institutional Review Board approval number for this study is #21150. Structured group interviews occurred in 2003. Clinical teaching observation was conducted in the summer of 2001, with follow-up visits as part of an empirical end-of-life communication study in the summer of 2002. Initially sparked by observations during clinical teaching rounds, this project resonates with Ellen Barton's call for “observational studies investigating the discourse of medicine” in “Design in Observational Research on the Discourse of Medicine: Toward Disciplined Interdisciplinarity,” Journal of Business and Technical Communication 13 (2001): 309. 8. I sometimes use the term “patients and families” to discuss a particular subgroup of stakeholders who deliberate at the end of life. Realizing that, in some cases, patients lack families or even distant relatives capable of making their medical decisions, I sometimes use the terms “proxy decision-makers” or “surrogate decision-makers,” abbreviated to “proxies” and “surrogates.” In each of these cases, I mean to refer to the person or group of people called upon to make decisions for a person whose decision-making capacity has been diminished by illness. Most often this means family, but it is important to note that it is sometimes otherwise. 9. The statistic is from William Rappaport, Christopher Prevel, Donald Witzke, John Fulginiti, Jeff Ballard, and Thomas Wachtel, “Education About Death and Dying During Surgical Residency,” The American Journal of Surgery 161 (1991): 690–92. The quotation is from Virginia P. Tilden, Susan W. Tolle, Michael J. Garland, and Christine A. Nelson, “Decisions About Life-Sustaining Treatment: Impact of Physicians’ Behaviors on the Family,” Archives of Internal Medicine 155 (1995): 633. 10. For a fascinating discussion of limitation of care and do-not-resuscitate forms, see William Ventres, Mark Nichter, Richard Reed, and Richard Frankel, “Limitation of Care: An Ethnographic Analysis,” The Journal of Clinical Ethics 4 (1993): 134–45. 11. Comparison to other code status sheets I have collected from other hospitals, those reproduced in Jacobson and Kasworm, “May I Take Your Order,” and eight forms considered in DePalo, Iacobucci and Crausman, “Do-not-Resuscitate and Stratification-of-Care,” forms the basis for this claim. 12. Michael J. Hyde, “Medicine, Rhetoric, and Euthanasia: A Case Study in the Workings of a Postmodern Discourse,” Quarterly Journal of Speech 79 (1993): 201. 13. Michael J. Hyde, The Call of Conscience: Heidegger and Levinas, Rhetoric and the Euthanasia Debate (Columbia: University of South Carolina Press, 2001). At a 2003 National Communication Association panel on rhetoric at the end of life, Texas A&M University's Barbara Sharf called for a return to Hyde's project of examining rhetoric at the end of life. 14. See, for example, Robert K. Kalwinsky, “Framing Life and Death: Physician-Assisted Suicide and The New York Times from 1991 to 1996,” Journal of Communication Inquiry 22 (1998): 93–112; and Michael J. Hyde, “Defining ‘Human Indignity’ in the Debate Over the (Im)Morality of Physician-Assisted Suicide,” Journal of Medical Humanities 21 (2001): 69–82. 15. Robert Wade Kenny, “Toward a Better Death: Applying Burkean Principles of Symbolic Action to Interpret Family Adaptation to Karen Ann Quinlan's Coma,” Health Communication 13 (2001): 363–84; “Thinking About Rethinking Life and Death: The Character and Rhetorical Function of Dramatic Irony in a Life Ethics Discourse,” Rhetoric and Public Affairs 6 (2003): 657–86; and “Resituating Rhetoric, Philosophy, and Poetics through the Call of Conscience: Michael J. Hyde on Heidegger and Levinas,” Quarterly Journal of Speech 88 (2002): 245–64. 16. Kalwinsky, “Framing.” 17. Todd F. McDorman, “Controlling Death: Bio-Power and the Right-to-Die Controversy,” Communication and Critical/Cultural Studies 2 (2005): 257–79. See the rhetoric of death and dying chapter in Judy Z. Segal, Health and the Rhetoric of Medicine (Carbondale: Southern Illinois University Press, 2005). This chapter is adapted from two previously published essays: “Contesting Death, Speaking of Dying,” Journal of Medical Humanities 21 (2000): 29-44; and “What is a Rhetoric of Death?: End of Life Decision-Making at a Psychiatric Hospital,” Technostyle 16 (2000): 67–86. 18. David J. Rothman, Strangers at the Bedside: A History of how Law and Bioethics Transformed Medical Decision Making (New York: Basic Books, 1991), 253. 19. Rothman, Strangers at the Bedside, 253. 20. W. B. Kouwenhoven, James R. Jude, and G. Guy Knickerbocker, “Closed-Chest Cardiac Massage,” Journal of the American Medical Association 173 (1960): 1064–67. 21. J. H. Talbott, as cited in Denis J. Fitzgerald, David P. Milzman, and Daniel P. Sulmasy, “Creating a Dignified Opinion: Ethical Considerations in the Formulation of Prehospital DNR Protocol,” American Journal of Emergency Medicine 13 (1995): 223. MI is a medical abbreviation for myocardial infarction—in non-medical terms, a heart attack. 22. Jeffrey P. Burns, Jeffrey Edwards, Judith Johnson, Ned H. Cassern, and Robert D. Truog, “Do-Not-Resuscitate Order After 25 Years,” Critical Care Medicine 31 (2003): 1543. 23. George P. Smith, “Euphemistic Codes and Tell-Tale Hearts: Humane Assistance in End of Life Cases,” Health Matrix: Journal of Law-Medicine 10 (2000): 176. 24. W. S. Summers, Sr., “Not Allowed to Die,” British Medical Journal 1, no. 589 (1968): 442. 25. Both Michael Hyde and Lisa Keränen have written about the Hippocratic ethic of medicine. Hyde discusses the relationship between rhetoric and Hippocratic medicine in the context of euthanasia in “Medicine, Rhetoric, and Euthanasia” and Call of Conscience, while Keränen interrogates medical schools’ use of the ideal of Hippocratic medicine in “The Hippocratic Oath as Epideictic Rhetoric: Reanimating Medicine's Past for Its Future,” Journal of Medical Humanities 21 (2001): 55–68. 26. Rothman, Strangers at the Bedside, 2. 27. For a discussion of death euphemisms from a health care professional, see Smith, Euphemistic Codes, 175–202. Gail Gazelle addresses the slow code issue in “The Slow Code—Should Anyone Rush to Its Defense?,” The New England Journal of Medicine 338 (1998): 467–69. 28. For an early discussion of medical futility, see Nancy S. Jecker and Lawrence J. Schneiderman, “Medical Futility: The Duty Not to Treat,” Cambridge Quarterly of Healthcare Ethics 2 (1993): 151–59. For a discussion of the ethics of not rushing to resuscitate all patients, see Gazelle, “The Slow Code.” 29. Burns et al., “Do-Not-Resuscitate Order.” 30. Burns et al., “Do-Not-Resuscitate Order,” 1543. 31. Rothman, Strangers at the Bedside. 32. Rothman, Strangers at the Bedside, 288. 33. American Heart Association, “Standards and Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (EEE),” Journal of the American Medical Association 227 (1974): 864–66. 34. Burns et al., “Do-Not-Resuscitate Order.” 35. Gregory L. Weiss and Charles Hite, “The Do-Not-Resuscitate Decision: the Context, Process, and Consequences of DNR Orders,” Death Studies 24 (2000): 322. 36. Mirarchi, What's the Patient's Code Status, 20. 37. Supreme Court of the State of New York, Report of the Special January 3rd, Additional 1983 Grand Jury Concerning ‘Do Not Resuscitate’ Procedures at a Certain Hospital in Queens County, cited in Rothman, Strangers at the Bedside, 237. 38. Rothman, Strangers at the Bedside, 253. 39. Good Care is only referred to as “Hospital” in citations. Copies of the policy authorizing the use of the Worksheet and other documents with identifying data redacted are on file with the author. See Hospital Policy on Advance Medical Directives and Determination of Withholding/Withdrawing Life Sustaining Treatment (2001), 1. 40. See Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. M. Sheridan Smith (New York: Vintage, 1994). 41. George Cheney and Jill J. McMillan, “Organizational Rhetoric and the Practice of Criticism,” Journal of Applied Communication Research 18(2): 93–114. During the last 15 years, scholars of organizational rhetoric have called for institutionally sensitive accounts of rhetoric's production and circulation. Among these are J. Michael Sproule's analyses of “new managerial rhetoric,” George Cheney's examinations of multiple identity management in postindustrial organizational rhetoric, and Stanley Deetz's focus on the hegemony of corporate values and managerialist ideology. J. Michael Sproule, “The New Managerial Rhetoric and the Old Criticism,” Quarterly Journal of Speech 74 (1988): 468–86; George Cheney, Rhetoric in an Organizational Society: Managing Multiple Identities (Columbia: University of South Carolina Press, 1991); and Stanley Deetz, Democracy in an Age of Corporate Colonization: Developments in Communication and the Politics of Everyday Life (Albany: State University of New York Press, 1992). Bill Kinsella has argued that rhetoric of science scholars must address the institutional aspects of big science. Surely, this argument extends to biomedicine, which is further complicated by its artistic and scientific poles. See William J. Kinsella, “Rhetoric, Action, and Agency in Institutionalized Science and Technology,” Technical Communication Quarterly 14 (2005): 303–10, http://www.proquest.umi.com, July 28. 42. Life-sustaining technologies permit families to exert a degree of control over the physiological presence of their dying loved one. Some families wait to withdraw care until a relative arrives from a distant locale, thereby preventing a declaration of death until a time that is convenient and meaningful for the family. 43. Jürgen Habermas, Toward a Rational Society, trans. J. Shapiro (Boston: Beacon Press, 1970). 44. The classical rhetorical treatment of argument spheres is G. Thomas Goodnight, “The Personal, Technical, and Public Spheres of Argument: A Speculative Inquiry into the Art of Public Deliberation,” Journal of the American Forensic Association 18 (1982): 214–27. Foucault calls death the “most private” aspect of existence on page 138 of The History of Sexuality, vol. 1, trans. Robert Hurley (Vintage: New York, 1990). 45. This case history was adapted from field notes taken during a clinical ethics practicum in an intensive care unit at a large urban tertiary care facility in the eastern United States in the summer of 2001. It has been condensed, amended, and stripped of most medical jargon and identifying details. Aspiring bioethicists are trained to write case histories in the fashion of doctors, to pare down “nonessential facts,” and winnow away detail that does not conform to convention. Mimicking the style of medical discourse is not only an attempt to bolster the credibility of bioethics by demonstrating that its practitioners can speak the language, so to speak—it also masks the rhetoricity of case histories by presenting a seemingly objective and scientific account. That bioethics case narratives frame our understanding of events and constrain decision-making by subtly favoring particular courses of action over others is discussed by Tod Chambers in The Fiction of Bioethics (New York: Routledge, 1999). The rhetorical dynamics of such write-ups are noted here but saved for later treatments of the topic. 46. Dylan Thomas, Do Not Go Gentle Into That Good Night, http://www.poets.org/viewmedia.php/prmmid/15377 (accessed June 16, 2006). 47. According to one palliative care and ethics committee, “physician desire to limit or withdraw life-sustaining treatments while patient or surrogates wish to ‘do everything’” is a recurrent conflict at the bedside. See Palliative Care and Ethics Committee, Managing Conflicts Concerning Requests to Withhold or Withdraw Life-Sustaining Medical Treatment (Milwaukee, WI: Froedhert Hospital), http://www.eperc.mcw.edu/educational%20materials/clinical/guide-conflicts.pdf (accessed July 20, 2006). 48. See Hyde, “Medicine, Rhetoric, and Euthanasia” and Call of Conscience, and Keränen, “The Hippocratic Oath.” 49. G. Thomas Goodnight, “The Personal, Technical, and Public Spheres,” 220. For other work on argument spheres, see Josh Boyd, “Public and Technical Interdependence: Regulatory Controversy, Out-law Discourse, and the Messy Case of Olestra,” Argumentation and Advocacy 39 (2002): 91–109; Valerie Fabj and Matthew Sobnosky, “AIDS Activism and the Rejuvenation of the Public Sphere,” Argumentation and Advocacy 31 (1995): 163–84; Lisa Keränen, “Mapping Misconduct: Demarcating Legitimate Science from ‘Fraud’ in the B-06 Lumpectomy Controversy,” Argumentation and Advocacy 42 (2005): 94–113; and Thomas Farrell and G. Thomas Goodnight, “Accidental Rhetoric: The Root Metaphors of Three Mile Island,” Communication Monographs 48 (1981): 271–300. 50. Timothy E. Quill, Death and Dignity: Making Choices and Taking Charge (New York: W. W. Norton, 1993). For a discussion of this case in Hyde's Call of Conscience, see pages 230–38. 51. Quill, Death and Dignity. 52. See Hyde, Call of Conscience. 53. Thomas L. Beauchamp and James F. Childress make the case for autonomy as the primary bioethical principal in Principles of Biomedical Ethics, 5th ed. (New York: Oxford University Press, 2001). While their to bioethics has been patient autonomy one of the values of See John and the of Public Debate University of Press, for a of See Beauchamp and John and What's with A Discourse to the of Patient Journal of Medical Ethics 24 (1998): the ethics of see E. and W. for Cambridge University Press, 1990). Hospital 1. Susan and James R. and and in of Studies of Science and and Hospital 7. Hospital 7. discusses how bioethical has rational in to the not while are that At Good physicians often the term to refer to the use of life-sustaining technologies in death was of this from the context of the intensive care and not be as in other death be with and Wilson, have the of an but of who use the “Patient” Preferences Worksheet at Good See Lisa Keränen, and Wilson, Code at the by the author at the for Bioethics and Health Law Grand at the University of Medical Psychiatric in For an of the see James W. Communication as on and (New York: Routledge, The of whether is a to was by in a Duty to is the of a bioethics essay written by John that a of See John a Duty to Report and to the in James M. and Robert F. a Duty to Press, Hyde, “Medicine, Rhetoric, and G. Ethics and Journal of Medical Humanities 24 (2003): See pages and in A. Hauser, The Rhetoric of and Public Spheres (Columbia: University of South 1999). includes a discussion of the of vernacular Michael Context, and the of Journal of Speech Communication James A. A. and Do Medical Resuscitation with Journal of Internal Medicine 10 (1995): Hyde, “Medicine, Rhetoric, and from an between a medical and a patient that was and in and Do Medical and Do Medical medical code status and at Good Care 25 these and as part of a and not of For a discussion of an to medical residents how to and end-of-life see K. J. Lisa B. Keränen, A. and Robert M. “The Palliative Care Clinical An for Teaching Communication Medicine (2005): Some for the of this moment the of code status forms on to the hospital, about or making code status part of and the in the towards of these has for most of is to J. and G. to about Palliative Care and Clinical Medicine (2000): on (New York: Michael Hyde this in The Call of Conscience. McDorman, “Controlling McDorman, “Controlling For Foucault, of with the of on and through the in that in the of producing McDorman, “Controlling McDorman, “Controlling Foucault, History of and Rhetorical Agency as Philosophy and Rhetoric and Communication and Critical/Cultural Studies 2 (2005): and and the Death of the the Rhetoric Quarterly (2005): Robert “The End of Report no. 6 (2005): that one person should be over end-of-life decisions, since an death R. “What About Rhetoric Quarterly The original on page of a the author in June the part the of on page of the of of on page The of Stephen John on the relationship between and in and the of University of Illinois Press, McDorman, “Controlling Hyde, Call of Conscience, Levinas, and the trans. R. PA: University Press, Hyde, Call of Conscience, Hyde, Call of Conscience, For treatments of in see W. The and Ethics University of Press, The and the (New York: Basic Books, The of Medical University Press, 1991); and Richard M. of Ethics and Press, 1993). For treatments of at the end of life by rhetorical see Segal, Health and the Rhetoric of and Hyde, Call of Conscience. Lawrence W. and Lisa Keränen, The of and in the Practice of in Health, and Communication and ed. M. and S. (New York: Lawrence This study was in Research and no. 2 24. by and on Life and Death (New York: 20. Quarterly Review 1 and 2 (accessed July 2006). Death and Dying (New York: 8. Death and 9. Thomas, Not Go Gentle Into That Good Hyde, Call of Conscience, John Lyne, the Life in The Rhetorical and in the of ed. W. University of Press, Michael in Medicine (New York: Oxford University Press, 2. See G. H. and J. The of the Clinic: in the of Medical and Discourse Lawrence This does not analyses of end-of-life (New York: 26. most work about is about (New York: 2005). 26. Additional on Keränen Lisa Keränen is of Communication and of the for Science and Policy Research at the University of at

Agency (philosophy) · Art · Autonomy · Linguistics · Literature · Paternalism · Political science · Rhetoric · Rhetorical question · Social science · Sociology · Worksheet · Ethics in medical practice · Law · Philosophy · Psychology

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