260 Code Status During Medical Emergencies: Are We Getting It Wrong?

Abstract

The prevalence of do-not-resuscitate(DNR)/do-not-intubate(DNI) orders has increased over time. It is estimated that up to 70% of patients now die with a DNR order in place. Despite this increase many patients still have preferences regarding the use of CPR and intubation that go undocumented and incompletely understood. Studies have demonstrated that patient preferences change both over time and with differing clinical scenarios. Reversal of code status is not uncommon, for example, in the perioperative period for a specific procedure. Whether patients fully comprehend their code status remains unknown. To assess patients' awareness and understanding of their code status as it applies to the hypothetical scenarios. We will also compare patients' preferences in hypothetical medical emergencies to their documented code status in order to assess factors that influence patients' DNR/DNI preferences. A prospective survey of patients with documented DNR/DNI code status was conducted from October 2010 to Aptil 2011. Patients were surveyed by a research assistant starting with a validated cognitive assessment. The researcher then administered the survey consisting of 4 scenarios of varying degrees of severity and reversibility (angioedema, pneumonia, severe stroke, and cardiac arrest). Each patient was asked whether they would agree to specific treatments in specific situations. They were also surveyed about who they would want to make health care decisions (previous declaration, family, or health care provider). Descriptive statistics with standard deviations (SD) and 95% confidence intervals (CI) were calculated using Microsoft Excel and SPSS 17. 53 patients were identified and screened, 3 patients failed the cognitive screen, 5 patients had code statuses inconsistent with DNR/DNI, and 2 patients were unable to complete the survey. Patients were aged 45-98 years (mean 82.3 ± SD 11.8) and had a Charlson co-morbidity index of 0-11 (mean 5.9 ± SD 2). 5% (CI 0-11%) of patients were not aware of their documented code status. Even though 95% of patients knew they had a documented code status of DNR/DNI, 64% (CI 49-79%) would want to be intubated in the face of a life threatening, but potentially reversible situation and 25% (CI 12-38) of patients would want a trial of resuscitation including intubation and CPR in the setting of cardiac arrest. The willingness to be intubated decreased with the potential reversibility of the disease process (P<0.0001). See table 1. Across all scenarios, 42% (CI 35-50%) would want their family to decide and 18% (CI 12-24%) would want their doctor to decide what is best for them.Tabled 1 Important discrepancies exist between patients' code status and their actual end of life preferences. These discrepancies may lead to the denial of lifesaving or life-prolonging care from patients who desire CPR and/or intubation. A better way of elucidating patient end of life preferences is needed.