Code Silver- How we can do better at the end of life from an Oncologist

All hands on deck for the most important discussion of them all

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Asking and Listening

Discussing goals of care at end of life for patients with metastatic or non-curable cancer should be the highest priority for an oncologist. We are experts in this disease of the highest of stakes- life or death. Full stop.

In most cases, we are in the privileged position of knowing our patients for months or years as they navigate metastatic cancer, meeting their families, learning their stories, understanding their humanity.

Ideally, this looks like serial conversations to ask and to listen, gather and document. I try to work these conversations in at milestone moments- initiation of new therapy, disease progression, good scans, new co-morbidities, life additions or subtractions like birth of a grandchild or death of a spouse. In these moments, there is a delicate balance of suffering and hope, but we are clearly moving forward- we are treating the cancer and that is the goal.

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A New Conversation

There comes a time when the cancer starts to win.

Serial progression in short time intervals, inability to recover such that life looks like being in bed for 14-16 hours of the day, or frequent hospitalizations are all signals to increase the urgency of these conversations. To enlist help from family members, palliative care providers, and most importantly the patient themselves. When the patient can describe their wants and needs, the grip of sadness and guilt on caregivers and loved ones is loosened. And when there is clarity about why treatment is continued or not continued, the inevitable suffering has definition and is maybe less traumatizing.

There is a heralding conversation where discussion turns to action. A decision is made to stop treatment. The pendulum swings from treating the cancer with medicines to improve or extend quality or quality of life to a focus on comfort without cancer medicines. This is a supremely intense discussion that takes place in the midst of routine workflows and as such, with competing attention and priority.

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Code Silver

I have thought about the concept of a structural system to consider how we can do better in the more urgent moments of decisions. I call this Code Silver.

Classifying a Code in medicine signifies a drop everything mentality. Various resources, human and otherwise, make a sudden moment a priority. In a Code Blue, doctors, nurses, respiratory therapist gather with lifesaving equipment at the bedside. ICU teams and social work are on alert for the outcome. A communication system is primed to get all of those people to the right place within moments.

A Code Silver would mirror the commitment, the infrastructure, and the urgency.

In an outpatient oncology clinic, when this definitive goal of care discussion is taking place, the oncologist calls a Code Silver to immediately mobilize a team. There is a pause and a re-set for the clinical team to close a door, make sure everyone has a seat, hush the waiting room, take a deep breath.

Financial counselors are triggered to get immediate authorization to know what options are available, which facilities are accepted by insurance or not. A representative from social work and hospice is alerted and appears in person to explain options concretely to patients and loved ones. A picture emerges and a plan is formulated, calmly and competently and with the utmost respect and compassion. Water is offered; hugs are given. Questions are answered and loops are closed.

This conversation and process should be elevated structurally to the position of importance it deserves. Thought, strategy, and resources should be designated to the end-of-life logistics as much or (arguably more) than how we handle sepsis and airway emergencies. Taking time and energy to think about death belongs in more spheres of conversation, health care in particular and oncology especially.

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