Code status discussion: Just have one

Abstract

code status discussion between a physician and a patient with cancer. The 2 videos were the same except that 1 video ended with the physician recommending a do-not-resuscitate (DNR) order for his patient, deemed by the investigators to be the ‘‘beneficence approach,’’ whereas the other video ended with the physician eliciting his patient’s choice of code status by asking a question, described as the ‘‘autonomy approach.’’ Participating patients were randomized to the sequence in which the videos were watched (recommendation video first or question video first). First, a note about methods. The recognized limitation of this study’s method (having all participants view both videos, thereby serving as their own control and lowering the necessary sample size), is that responses to the second intervention are biased by the first. The investigators overcome this built-in bias by basing their conclusions about what influenced DNR choice only on participants’ responses to the first video. However, in their prior work using the same methodology to compare patients’ reactions to sitting versus standing physicians delivering ‘‘bad news,’’ 2,3 patients rated the second physician as more compassionate despite their overall preference for the sitting physician. No such shift was observed in this study. The investigators suggest the high degree of compassion exhibited by the physician in the video may have masked patients’ tendency to shift their perception of compassion, and its impact on their DNR choice. Another likely explanation for patients’ consistency is the often-found phenomenon that individuals are strongly biased toward being consistent in their choices 4 to avoid cognitive dissonance. 5 The investigators’ hypothesis, that patients would more frequently choose DNR for the patient in the first video when the discussion ended with a recommendation, was not supported. The type of ending did not appear to impact DNR choice. This result is surprising. It is well established in other contexts that a physician’s recommendation is influential and sometimes determinative of patients’ choices. 6-8 Why this different result within this context?