60 A review of code status documentation in patients referred to the palliative care inpatient consult service

Abstract

Background Inpatient Palliative Care consult services see a wide range of acutely admitted patients, many of whom are critically ill. Due to the nature of an acute admission, code status clarification or discussion is often overlooked and can affect patient’s clinical course and outcome. Objectives To investigate the documentation of code status discussion on admission to hospital. To investigate patient outcomes in those referred to Palliative care services. Methods The electronic health records (EHR) of 50 patients referred to the Palliative Care consult service were retrospectively reviewed, following Institutional Review Board (IRB) approval. The patients code status orders, clinical notes, and outcomes were documented. Results The average age of the patients was 67.86 years. 48% had an active cancer diagnosis, 10% were left ventricular device (LVAD) patients and 42% had an acute cardiac, pulmonary or neurological presentation. 34% of patients were admitted directly to an intensive care setting. The majority (80%) of patients were ‘Full Code’ on admission, 12% were ‘Do Not Resuscitate’ (DNR) and 8% were ‘Partial Code’. For those who were documented as ‘DNR’, only 1 patient had a documented ‘Do Not Intubate’ (DNI) order. While code status was documented in all admission notes, the discussion of code status clarification was only documented in 14% of notes. Only one emergency department note referenced a discussion of code status. Code status was changed within 24 hours in 6% of patients, and 20% of patients changed code status during admission, with Palliative Care involvement in the majority (80%) of these cases. Regarding outcomes, 56% returned home, 14% were discharged for rehabilitation, 22% were discharged with hospice care, and 6% died in hospital on comfort care. Conclusion Code status discussion should be an integral part of an acute hospital admission to ensure patient’s wishes are being followed and respected.