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Original article

Vol. 150 No. 1314 (2020)

Code status discussions in medical inpatients: results of a survey of patients and physicians

DOI
https://doi.org/10.4414/smw.2020.20194
Cite this as:
Swiss Med Wkly. 2020;150:w20194
Published
23.03.2020

Abstract

INTRODUCTION

Code status discussions are useful for understanding patients’ preferences in the case of a cardiac/pulmonary arrest. These discussions can also provide patients with a basis for informed decision-making regarding life-sustaining treatment. We conducted a survey to understand current practices and perceptions of code status discussions in a tertiary-care Swiss hospital.

METHODS

We performed systematic interviews across different departments of the University Hospital of Basel. We interviewed 258 physicians and 145 patients who were hospitalised between May and July 2018 using a questionnaire designed to assess the use of code status discussions and to gauge patients’ individual experiences and opinions.

RESULTS

A total of 61.4% of patients did not recall having had a code status discussion during the hospital stay. However, a higher proportion of medical patients compared to surgical patients recalled having had a discussion (43.6 vs 22.4%, p = 0.03). For 9 out of 38 (23.7%) patients who did recall the discussion, there was a lack of agreement between the preference given in the interview regarding resuscitation measures and the documented code status in the medical electronic chart. Furthermore, a majority of physicians (72.4%) recalled defining a do-not-resuscitate (DNR) status for a patient without prior discussion with the patient. Physicians who recalled determining the DNR status without patient consultation reported conflicts with patients and relatives regarding code status at a higher rate compared to physicians who did not define DNR status without consultation (62.4 vs 39.4%, p <0.001).

CONCLUSION

A majority of patients do not report having discussed code status during their hospital stay and physicians frequently omit such discussions, thereby potentially failing to attend to patients’ preferences for care. Physician training regarding code status discussions may improve the quality of informed decision-making and patient-centred care.

References

  1. Wissenschaften SAdM (SAMW). Reanimationsentscheidungen. 2017.
  2. Margolis B Blinderman C de Meritens AB Chatterjee-Paer S Ratan RB Prigerson HG Educational Intervention to Improve Code Status Discussion Proficiency Among Obstetrics and Gynecology Residents. Am J Hosp Palliat Care. 2018;35(4):724–30. doi:.https://doi.org/10.1177/1049909117733436
  3. Sulmasy DP Sood JR Ury WA. Physicians’ confidence in discussing do not resuscitate orders with patients and surrogates. J Med Ethics. 2008;34(2):96–101. doi:.https://doi.org/10.1136/jme.2006.019323
  4. Rosenberg LB Greenwald J Caponi B Doshi A Epstein H Frank J Confidence with and Barriers to Serious Illness Communication: A National Survey of Hospitalists. J Palliat Med. 2017;20(9):1013–9. doi:.https://doi.org/10.1089/jpm.2016.0515
  5. Mills LM Rhoads C Curtis JR. Medical Student Training on Code Status Discussions: How Far Have We Come? J Palliat Med. 2016;19(3):323–5. doi:.https://doi.org/10.1089/jpm.2015.0125
  6. Syed AA Almas A Naeem Q Malik UF Muhammad T. Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study. Palliat Med. 2017;31(2):147–57. doi:.https://doi.org/10.1177/0269216316650789
  7. Edlich RF Kübler-Ross E. On death and dying in the emergency department. J Emerg Med. 1992;10(2):225–9. doi:.https://doi.org/10.1016/0736-4679(92)90231-H
  8. Robinson MA. Informing the family of sudden death. Am Fam Physician. 1981;23(4):115–8.
  9. Barnett MM Fisher JD Cooke H James PR Dale J. Breaking bad news: consultants’ experience, previous education and views on educational format and timing. Med Educ. 2007;41(10):947–56. doi:.https://doi.org/10.1111/j.1365-2923.2007.02832.x
  10. Tulsky JA Chesney MA Lo B. How do medical residents discuss resuscitation with patients? J Gen Intern Med. 1995;10(8):436–42. doi:.https://doi.org/10.1007/BF02599915
  11. Jordan K Elliott JO Wall S Saul E Sheth R Coffman J. Associations with resuscitation choice: Do not resuscitate, full code or undecided. Patient Educ Couns. 2016;99(5):823–9. doi:.https://doi.org/10.1016/j.pec.2015.11.027
  12. Fischer GS Tulsky JA Rose MR Siminoff LA Arnold RM. Patient knowledge and physician predictions of treatment preferences after discussion of advance directives. J Gen Intern Med. 1998;13(7):447–54. doi:.https://doi.org/10.1046/j.1525-1497.1998.00133.x
  13. Kanoti GA Gombeski WR Jr Gulledge AD Konrad D Collins R Medendorp SV. The effect of do-not-resuscitate orders on length of stay. Cleve Clin J Med. 1992;59(6):591–4. doi:.https://doi.org/10.3949/ccjm.59.6.591
  14. De Jonge KE Sulmasy DP Gold KG Epstein A Harper MG Eisenberg JM The timing of do-not-resuscitate orders and hospital costs. J Gen Intern Med. 1999;14(3):190–2. doi:.https://doi.org/10.1046/j.1525-1497.1999.00312.x
  15. Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Regional variation in the incidence and outcomes of in-hospital cardiac arrest in the United States. Circulation. 2015;131(16):1415–25. doi:.https://doi.org/10.1161/CIRCULATIONAHA.114.014542
  16. Partridge JS Harari D Dhesi JK. Frailty in the older surgical patient: a review. Age Ageing. 2012;41(2):142–7. doi:.https://doi.org/10.1093/ageing/afr182
  17. Truog RD Waisel DB Burns JP. Do-not-resuscitate orders in the surgical setting. Lancet. 2005;365(9461):733–5. doi:.https://doi.org/10.1016/S0140-6736(05)17999-9
  18. Scott TH Gavrin JR. Palliative surgery in the do-not-resuscitate patient: ethics and practical suggestions for management. Anesthesiol Clin. 2012;30(1):1–12. doi:.https://doi.org/10.1016/j.anclin.2012.02.001
  19. Rabkin MT Gillerman G Rice NR. Orders not to resuscitate. N Engl J Med. 1976;295(7):364–6. doi:.https://doi.org/10.1056/NEJM197608122950705
  20. Optimum care for hopelessly ill patients. A report of the Clinical Care Committee of the Massachusetts General Hospital. N Engl J Med. 1976;295(7):362–4. doi:.https://doi.org/10.1056/NEJM197608122950704
  21. Waisel DB Simon R Truog RD Baboolal H Raemer DB. Anesthesiologist management of perioperative do-not-resuscitate orders: a simulation-based experiment. Simul Healthc. 2009;4(2):70–6. doi:.https://doi.org/10.1097/SIH.0b013e31819e137b
  22. Sprung J Warner ME Contreras MG Schroeder DR Beighley CM Wilson GA Predictors of survival following cardiac arrest in patients undergoing noncardiac surgery: a study of 518,294 patients at a tertiary referral center. Anesthesiology. 2003;99(2):259–69. doi:.https://doi.org/10.1097/00000542-200308000-00006
  23. Kazaure HS Roman SA Rosenthal RA Sosa JA. Cardiac arrest among surgical patients: an analysis of incidence, patient characteristics, and outcomes in ACS-NSQIP. JAMA Surg. 2013;148(1):14–21. doi:.https://doi.org/10.1001/jamasurg.2013.671
  24. Young KA Wordingham SE Strand JJ Roger VL Dunlay SM. Discordance of Patient-Reported and Clinician-Ordered Resuscitation Status in Patients Hospitalized With Acute Decompensated Heart Failure. J Pain Symptom Manage. 2017;53(4):745–50. doi:.https://doi.org/10.1016/j.jpainsymman.2016.11.010
  25. Indra P, Frey B. eHealth und Elektronisches Patientendossier. Tribune. August 2017:4-5.
  26. The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995;274(20):1591–8. doi:.https://doi.org/10.1001/jama.1995.03530200027032
  27. Adams DH Snedden DP. How misconceptions among elderly patients regarding survival outcomes of inpatient cardiopulmonary resuscitation affect do-not-resuscitate orders. J Am Osteopath Assoc. 2006;106(7):402–4.
  28. Jones GK Brewer KL Garrison HG. Public expectations of survival following cardiopulmonary resuscitation. Acad Emerg Med. 2000;7(1):48–53. doi:.https://doi.org/10.1111/j.1553-2712.2000.tb01891.x
  29. Becker C Lecheler L Hochstrasser S Metzger KA Widmer M Thommen EB Association of Communication Interventions to Discuss Code Status With Patient Decisions for Do-Not-Resuscitate Orders: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(6):e195033. doi:.https://doi.org/10.1001/jamanetworkopen.2019.5033
  30. Vilpert S Borrat-Besson C Maurer J Borasio GD. Awareness, approval and completion of advance directives in older adults in Switzerland. Swiss Med Wkly. 2018;148:w14642. doi:.https://doi.org/10.4414/smw.2018.14642

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